Membership Application APGANZ Inc.
Please complete all details below
Email address *
First Name *
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Surname *
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Date of Birth *
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Phone *
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Postal address *
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Current Employer *
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Position/Profession: *
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Referee Name: *
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Referee Email Address (if known)
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Referee Phone: (If known)
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I authorise the verification of the information provided on this form *
Membership fees for 2019 are $35.00 and payable in May of each year.
Please make any payments directly to our account, details below:
Bank: Kiwi Bank Account name: Abortion Providers Group AOTEAROA New Zealand Incorporated Account number: 38 9016 0847880 00
Gst Reg: 117053059
A copy of your responses will be emailed to the address you provided.
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