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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   RETURNED / SERVICE   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_________________________________________________________________________

 

Type of Service:         (circle)            Army             Navy                Airforce           Police                Other

 

Force Served with Overseas:___________________________________Service No:_____________

 

War / Conflict Service In:____________________________________________________________

 

Relevant Dates in Theatre:___________________________________________________________

 

Date Discharged:__________________________________________________________________

 

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:____________________________________________________________________