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 Title *
Your first name *
Your family name *
Your address *
Street, suburb and city
Your landline or mobile phone number *
Enter numbers only. No spaces or other characters please.
Your email address *
We will email you a confirming copy of your application.
Your Date of Birth *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.