SeniorNet West Auckland Inc.

Membership Renewal Form 2021  

AMI Customer number if you have one..................... (qualifies for free membership)

Title….: Surname: ………………….…………….… First Name/s…………….…………….…...

Street Address: ……………………………………Suburb: ……………………………City: …………………………………….

Post Code: ……………… (Important) Contact Phone No: ………………………………….

Contact name & phone No. to call in case of emergency

Email Address: ……………………………………………………………. …….……..Print Clearly

We require your email address for advising our Club activities.

Previous occupation (Optional)………………………………………………………………………..

For funding purposes we need to know your gender, age, ethnic groupings & residency status.

Please tick boxes as applicable:

M

F

50-59

60+

European

Maori

Pacific Is

Asian

NZ Resident

Non NZ Resident











What operating system are you using. Windows 7, Windows10, Ipad, Samsung Galaxy, Android, Iphone and Samsung Phones or name your Tablet or Phone name ……….. or  don’t know. (Circle as applicable).

No fee charged for AMI customers with an AMI customer number.  Annual Subscription: 1st January – 31st December 2021.

Renewal - $25.00. Single. Class fees extra.

Renewal - $45.00. Couples. Class fees extra.

Students will be contacted by phone as soon as a course is available.

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 organisation’s business. You may at any time request a copy of your information.

Signed: ………………………………………. Date: ………………………

___________________________________________________________________________________

Please complete this and forward with a cheque payable to SeniorNet West Auckland Inc,C/- Membership Secretary, 33/18 Williams Road, Hobsonville Auckland 0618

Online Payment: To SeniorNet West Auckland account 12 3100 0154721 00. In the first reference field enter ”Renew.”

Enter your first name in the second field and your last name in the third field. Send the form as well when paying on line.  

Club Use Only: Receipt No: ……………….. Date: ………………..