Online applicationThank you for taking the first steps to joining out club, we are a family here and as so we create a very friendly environment. Name* First Last Are you known by other name?* Yes No If yes, please indicate* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone*Date of Birth* MM slash DD slash YYYY Other Club MembershipHas your membership ever been declined, suspended or revoked from any club?* Yes No If YES name of club and details:* Privacy Act 19931. The above named Club is collecting and will hold, the information on this form. the Club is collecting the information. 1 a. so it and its members can assess the applicants suitability for membership (including transfers of membership): 1 b. so it can administer its operation and assist other Clubs that are members on Clubs NZ to admininister theirs.. 3 c. to enable Clubs NZ or its agents to complie a list of members of all clubs in New Zealand and to send those members promotional, marketing and other material 2. a copy of this information and photograph of the applicant will be displayed on the Club Noticeboard for 14 days. 3. The applicant acknowledges by signing this form that he or she has authorized the Club to obtain, check,exchange informatiion with, and supply information to members of the Cluib, Clubs NZ and other Clubs that are members of Clubs NZ. 4. The applicant is entitled, under the Privacy Act 1993 to have access to, and request correction of personal information held by the Club by the applicantConsent* I agree to the privacy policy.1. The above named Club is collecting and will hold, the information on this form. the Club is collecting the information. 1 a. so it and its members can assess the applicants suitability for membership (including transfers of membership): 1 b. so it can administer its operation and assist other Clubs that are members on Clubs NZ to admininister theirs.. 3 c. to enable Clubs NZ or its agents to complie a list of members of all clubs in New Zealand and to send those members promotional, marketing and other material 2. a copy of this information and photograph of the applicant will be displayed on the Club Noticeboard for 14 days. 3. The applicant acknowledges by signing this form that he or she has authorized the Club to obtain, check,exchange informatiion with, and supply information to members of the Cluib, Clubs NZ and other Clubs that are members of Clubs NZ. 4 The applicant is entitled, under the Privacy Act 1993 to have access to, and request correction of personal information held by the Club by the applicantDeclaration* I hereby agree to abide by the rules of the Club and certify that the above information is correct. I acknowledge that if i have given false information it will result in automatic cancellation of membership.I have read the above statement and agree that all is correct and proper with me filling out the above form. *Date of Application* MM slash DD slash YYYY
