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Membership Application Form
2008/2009 (Please
Print) Mr/Mrs/Ms:
Surname:
.
.
. First Name:
...
.
... Street
Address:
Suburb:
City:
.
.
. Post
Code:
(Important)
Contact
Phone No
.: Email
Address:
Print
Clearly We
require your email address for advising of Club activities Contact
Name & phone No. to call in case of emergency:
..
For
funding purposes we need to know your gender, age, ethnic groupings
& residency status. Please
tick boxes as applicable:
What
Operating System are you using? Windows 95; Windows 98; Windows ME;
Windows XP; Windows Vista or Dont Know. (Circle as applicable). Annual
Subscription: 1st October 2008 to 30th September 2009. Single
- $20.00
Double - $30.00
(This is applicable to a couple living at the same address.) Students
will be contacted by phone as soon as a course is available. Classes
are Held:
Monday
Wednesday Thursday
Friday
Select
morning 10am or afternoon
1pm sessions. (2 Hours each Lesson) Under
the Privacy Act 1993, we advise that the information provided on this
application form will be entered into our membership computer database
and will only be used for our organisations business. You may at any
time request a copy of your information. Declaration:
I/we are over the age of 50years
(You must be 50 yrs or over to join SeniorNet) Signed:
.
.
Date:
Please
complete this and forward with a cheque, payable
to SeniorNet West Auckland Inc. SeniorNet
West Auckland C/-
Jose McKelvey 193
Te Atatu Rd Te
Atatu South 0610
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