Your Name: (required)


Your House No. & Street Name: (required)


Your Suburb Name: (required)


Your City Name: (required)


Your Email: (required)


Your Mobile No.: (required)


Your Occupation: (required)


Your Marital Status: (required)
MarriedSingleDivorcedWidower

Your Immigration Status: (required)
NZ CitizenPermanent ResidentStudent VisaWork VisaVisitor Visa

Are you a Donor:
BloodOrganBothNot a Donor

Membership Type: (required)
IndividualFamily

Declaration:
I, the above named applicant do hereby solemnly and sincerely declare that the above particulars are true and correct to the best of my knowledge.
I confirm that I have read the rules and regulations of the Club and agree to abide by the same.