Title .: Surname: . . First Name/s . . ...
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:
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 Dont Know. (Circle as applicable).
Annual Subscription: 1st January 31st December 2019
Subscription - $30.00. Class Fees extra
Couples- $50.00. Class Fees Extra
Students will be contacted by phone as soon as a course is available.
Select: 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 organisations 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,
SeniorNet West Auckland Inc. PLEASE DO NOT STAPLE CHEQUE TO
C/- Membership Secretary APPLICATION FORM
33/18 Williams Road, Hobsonville
Online Payment: SeniorNet West Auckland, 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. Please remember to send the form as well, when paying on line