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Katikati RSA & Citizens Club (Inc)

Application for Membership

(Please print this out)

Applicant:

Surname:____________________________    First Names:__________________________________

D.O.B. _____ /_____/________             E/Mail:___________________________________________

Address:_______________________________________________________________

______________________________________________________________________

Phone: (Home)_________________________   ( Work)__________________________

Has your membership ever been declined, suspended or revoked from any other club?   Yes   /    No

I hereby to 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. I enclose $30 being payment of the nomination fee and a recent photograph of myself (passport style)

Signature of Applicant:__________________________________   Date:________________

Upon acceptance as a member of the club the applicant shall receive an account for the current year's subscription, which is to be paid at the office of the club within seven days. If payment is not received within this period the membership becomes invalid.

We acknowledge the applicant personally and in accordance with the rules, recommend him/her for membership.

Proposer:              I have known the applicant _________ years

Signature:___________________________________   Membership No:_____________

Seconder:             I have known the applicant ________  Years

Signature:___________________________________   Membership No:_____________

Privacy Act 1983: The above club is collection, and will hold, the information on this form. The club is collecting the information. a. so it and its members, can assess the applicant's suitability for membership (including any transfers of membership) b. so it can administer its operation and assist other clubs that are members of Clubs NZ (CNZ) to administer theirs. c. to enable CNZ, or its agent to compile a list of members of all clubs in New Zealand and to send those members promotional, marketing and other material. A copy of this application and photograph of the applicant will be displayed on the club notice board. The applicant acknowledges by signing this form that he or she has authorised the club to obtain, check, exchange the information with, and supply information to, members of the club, CNZ, and other clubs that are members of CNZ. The applicant is entitled, under the Privacy Act 1983 to have access to and request correction of, personal information held by the Club about the applicant.