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.

This is a required question

Is this application for you alone, or part of a joint application?

This application is for me alone (Subscription rate $25 per annum)
This application is part of a joint application where my spouse is also joining at this time (Combined subscription $40 per annum)
This application is part of a joint application where my spouse is already a member. (Combined subscription rate $40 per annum)

This is a required question

Spouses name?

This information is required ONLY in the event you are submitting a joint application. Otherwise, leave it blank.

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Your Title

This is a required question

Your first name

This is a required question

Your family name

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Your address

Street, suburb and city

Too many words. Try again.

This is a required question

Post Code

This is a required question

Your landline phone number

This is a required question

Your email address

We will email you a confirming copy of your application.

Not an email address

This is a required question

Your Date of Birth