HOME                                        Membership Application Form

 

Mr/Mrs/Ms        SURNAME:                                                      FIRST NAMES:

 

________________________________________________________________________________

Are you or have you ever been know by another name?                            Yes / No

 

If YES please print the name here in full:  _____________________________________________

______________________________________________________________________________________

I hereby agree to abide by the rules of the Club and certify that the information provided on the Application Form is correct. I acknowledge that if I have given false information, it could result in automatic cancellation of my application and/or membership.

 

Applicants Signature:_____________________________________     Date:_______________

 

Proposer and Seconder must be a financial member for 12 months or more.

Proposer / Seconder Details - Please print your names.

 

Proposed by:____________________________________   Membership No:_____________

 

I have know the applicant for    ___________  years        Signed:__________________________

 

Seconded By:____________________________________  Membership No:______________

 

I have known the applicant for  ___________  years         Signed:__________________________

 

 

 

 

Affix photo here

 

 

 

Privacy Act 1993:

The Club is collecting and will hold the information on the form. This information is required.

a. so the Club and its members can assess the applicant suitability for membership including transfer of membership. b. so it can administer its operation and assist other Clubs affiliated with Clubs NZ to administer theirs.

 

A copy of the first part of this application form and photograph of the applicant will be displayed on the Club Notice Board. The Applicant acknowledges by signing this form that he or she has authorised the Club to obtain, check, exchange information with and supply information to members of the Club, Clubs NZ and Clubs that are members of Club NZ. The applicant is entitled under the Privacy Act 1993 to have access to, and request correction to personal information held by the Club.

 

Subscriptions:  $26 annually to be paid at time of application

Subscriptions are due for renewal at 31st March each year.

 

For the Privacy of the Applicant, the section below should be folded back before photocopying the top section for posting on the Club Notice Board.

 

Applicant to complete:  Address:____________________________________________________

 

_________________________________________________________________________________

 

Contact Phone:___________________ Fax (if any)__________________Mobile:_________________

 

E/mail Address:_____________________________________________ Date of Birth:____________

 

Has your Membership ever been declined, suspended or revoked from any other Club?   YES / NO

Do you have any Criminal Convictions?          YES / NO

 

If YES -- Details___________________________________________________________________

 

Office Use Only: Date Received:_____________Date Accepted:____________ Declined:_______

 

Membership No:___________________        Receipt No: _______________________