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.
* Required
Section 1 - You
Are You A Previous Member of SeniorNet Hutt City Inc.
*
Information used for our database updates.
No
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
*
Choose
Mr
Mrs
Ms
Dr
Other
Your first name
*
Your answer
Your family name
*
Your answer
Your address
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Street, suburb and city
Your answer
Post Code
*
Postcode finder here
http://www.nzpost.co.nz/tools/address-postcode-finder
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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