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Text Box: Attach a small colour photo of yourself.   Passport or similar photo.         We can slightly enlarge a photocopy your drivers licence.

 

FOXTON RETURNED AND SERVICES ASSOCIATION (INC)

 

APPLICATION FOR  ASSOCIATE MEMBERSHIP

 

Surname:_________________________________________Mr / Mrs / Ms                                              

 

First Name/s:______________________________________________________

 

Address:_________________________________________________________

 

_____________________________________________________________________________

 

Phone No:________________________Email:____________________________________________

 

Mobile No:________________________Date of Birth:_____________________________________

 

Next of Kin:__________________________________________Phone:_____________________

 

Relationship to you_________________________________________________________

 

Address_________________________________________________________________

 

Proposer:______________________________________________________ Print Name and Sign

 

Seconder:_____________________________________________________  Print Name and Sign

 

 

Disclosure under the Privacy Act 1993.

I consent to the collection of the above attached details by the Foxton RSA Assn Inc for the purpose of a club membership record and for it to retain, use and disclose these to NZRSA, NZCC and other agencies necessary to the good running of the club.  I acknowledge my rights to access and correction of this information.  This consent is given in accordance with the Privacy Act 1993.

 

 

Signed:__________________________________________________

 

Date:____________________________

   

     Details to be placed on notice board for members to view.

 

    Surname:__________________________________________Mr / Mrs / Ms

 

   First Name/s:__________________________________________________