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Tauranga Citizens' Club (Inc)

P.O. Box 2251, Seventh Ave, Tauranga   3140

Senior Membership Application Form

 

                                                                                                                               Affix photo here

Privacy Act 1993                                                                                                                  

The Club is collecting, and will hold, the information on this form.

The information is required:

(a) so it, and its members, can assess the applicant's suitability for membership

(b) so it can administer its operation and assist other clubs affiliated with

Clubs New Zealand 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 for a period of 14 days during which time any objection to the application may be

lodged.

 

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 New Zealand and clubs that are members of Cubs New Zealand. The applicant is entitled, under the Privacy Act 1993

to have access to, and request correction of, personal information held by the club about the applicant.

 

Mr/Mrs/Miss/Ms

Surname:

  

First Names:

 

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

If YES, please write the name here in full:

 

I hereby agree to abide by the rules of the club and certify that the information provided on this 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. I certify that I am not suspended, nor expelled, from another club.

 

I enclose payment for $17.77 +GST =$20.00  payable to the club, being full payment of the nomination fee*

* On acceptance as a member of the club, you will receive an account for the current year's subscription which is to be paid at the Office within 30 days. If payment is not received within this period the membership becomes invalid.

 

Signature of applicant:   ..........................................................................Date: .........................

 

 

 

Proposer / Seconder Details --------- Please print your name

 

 

 

 

Proposed by.................................................................................Membership No:....................

 

I have known the applicant for..................... years             Signed:

 

 

 

 

 

 

Seconded by................................................................................Membership No:......................

 

I have known the applicant for ................... years              Signed:

 

 

Applicant to Complete:

 

ADDRESS: Residential                                                               Postal if different

 
Contact Tel. No: Fax (if any)
Mobile Phone: E/Mail:
Date of Birth: Occupation

 

Clubs New Zealand is exploring the possibility of a national members card. It is envisaged that this card

would entitle members to discounts at retail outlets in New Zealand.

 

For this project to proceed Clubs New Zealand requires the approval of its members to submit their details

to a National Database.

 

Please delete one:

I hereby give authority for my membership details to be given to Clubs New Zealand for the purpose

of a future discount card.

 

I do not wish my details to be forwarded to Clubs New Zealand.

 

Signed:........................................................................

 

 

Have you --

1. Included payment of $20.00

2. Included passport size photo

3. Had this form signed by Proposer and Seconder (Who must have been a financial member of

the club for more than 12 months)

 

 

 

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