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.

Yes

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)

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

Post Code *

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 *

YYYY

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