SeniorNet Hutt City Inc. Membership Application Form
Complete and send this form, and arrange payment of the initial subscription fee.

You need a valid email address to apply on line.

Our New Member Co-ordinator will contact you in due course to discuss how SeniorNet may best meet your learning needs.

Section 1 - You
Are You A Previous Member of SeniorNet Hutt City Inc. *
Information used for our database updates.
Is this application for you alone, or part of a joint application? *
Spouses name?
This information is required ONLY in the event you are submitting a joint application. Otherwise, leave it blank.
Your answer
Your Title *
Your first name *
Your answer
Your family name *
Your answer
Your address *
Street, suburb and city
Your answer
Your answer
Your landline or mobile phone number *
Enter numbers only. No spaces or other characters please.
Your answer
Your email address *
We will email you a confirming copy of your application.
Your answer
Your Date of Birth *
MM
/
DD
/
YYYY
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