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Application to Join SeniorNet West Auckland
SeniorNet West Auckland Inc
P.O.Box 69016
Glendene,
Auckland
ONLINE PAYMENT: Log on to your bank and go to one off payments. Copy the following account number 12-3100-0154721-00 into the payee field.
MOST IMPORTANT: Enter "Join" in the first reference field. Enter your first name in the next field & surname in the third space
Annual Subscription: 1st January to 31st December.
First Name
*
Surname
*
Address
*
Street
*
Suburb & Postal Code
Landline phone number
*
Mobile phone number
Email
Contact name & phone number of person to contact in an emergency
*
For funding purposes we need to know your gender, age, ethnic groupings & residency status.
Please tick boxes as applicable:
*
M
F
50 to 59
60 plus
European
Pacificic Islands
Non Nz resident
Maori
Nz resident
Joining / Subscription Fee
*
$30.00
I have paid online
I am paying by cheque
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