Membership Application Form

New Brighton Club

Mr/Mrs/Miss/Ms: Mr Surname: Elley
Name Gordon
Address 2/430 Pine Ave
Contact Telephone 0274291975
Mobile 0274291975
Occupation Self Employed
Date of Birth 06/02/1961
Are you, or have you ever been known by another name? No
If YES, please write your name in full
Membership Pack Posted? Pickup? Pick-up

Further Important Details

Office Use Only

Name: Gordon Elley Address: 2/430 Pine Ave
Date: 10/30/2018, 1:39:42 PM Date to: Amount: $26.00 Membership:

Privacy Act 1993. The Club is collecting, and will hold, the information on this form.

The information is required:

  • So it and its members, can assess the applicants suitability for membership (including transfer of membership)
  • So it can administer it’s operation and assist other Clubs affiliated with Clubs New Zealand to administer theirs

Following the Rules Committee Meeting your name will be displayed on the Club Notice Board for 7 clear days. The applicant acknowledges by signing this form that he or she has authorized the Club to obtain, check, exchange information with, and supply information to, members of the Club, Clubs of New Zealand and Clubs that are members of Clubs New Zealand. 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. I hereby agree to abide by the Rules of the Club and certify that the information provided on the application form is correct. I acknowledge that if I have given false information, it could result in automatic cancellation of my application and/or membership. I certify that I am not suspended or expelled from another Club.

SIGNATURE ***SIGNED ELECTRONICALLY*** Date: 10/30/2018, 1:39:42 PM