Membership Application Form

For the printable version of the Club Application form Click here

APPLICATION FOR MEMBERSHIP OF: KAPITI CLUB (INC.)

Applicant Details

* = Must Complete

Please tick box if applying for Joint Membership and fill in separate forms

* Surname * Fore Name(s)
* Address

* Your Email * Date of Birth
* Phone * Mobile

Has your Membership ever been declined, suspended or revoked from any Club? YES No
If YES Name of Club and details:

Nomination

Please supply details of current club members willing to nominate you as a new member
Proposer: Membership number
I have known this person for Years
Seconder: Membership number
I have known this person for Years

NOTE: you will also need to supply a photo of yourself - please email this ASAP to info@kapiticlub.co.nz or drop it in to our office at the club (please ensure your name is with your photo if you are emailing it)

If you are new to the area and unfortunately you don't have anyone to nominate you please ph the club 04-298-4031 to discuss your options.

Privacy Act

1. The above named club is collecting, and will hold, the information on this form. The club is collecting the information:

2. The applicant acknowledges by signing this form that he or she has authorised the club to obtain, check, exchange information with, and supply information to, members of the club, NZCC and other clubs that are members of NZCC.

3. The applicant is entitled, under the Privacy Act 1993 to have access to, and request correction of, personal information held by the club about the applicant.

Tick the box if you do not agree to being sent material described in 1c above.

Upon acceptance of your application you will be sent an invoice for the application fee of $50 plus your current subscription.

I hereby agree to abide by the rules of the club and certify that the above information is correct. I acknowledge that if I have given false information, it will result in automatic cancellation of membership.

Kapiti Club