Home Page                                                                          Printable Version

Application for Membership

Otorohanga Club (Inc)

SURNAME (Please Print):_____________________________________

FORE NAMES (Please Print): __________________________________________________

OCCUPATION:_____________________________________________________________

Are you or have you been known by any other name?            Yes  /  No

If yes what name:______________________________________________________________

ADDRESS:__________________________________________________________________

PHONE:___________________________________  Date of Birth:______________________

E/mail Address:_______________________________________________________________

Have you been refused or had your membership revoked from any other club?      Yes  /  No

If yes name of club and details:_______________________________________________________

Enclosed is $20 being full payment for this nomination. On acceptance as a member of the Club the applicant shall receive an account for the current years subscription which is to be paid to the office of the Club within 14 days.

If payment is not received within this period this nomination becomes invalid. Your temporary membership card expires on this date.

I hereby agree to abide by the rules of the Club and certify that the above information is correct.

Signature:        ________________________________________      Date:_______________

If any of the information given is false it will result in automatic cancellation of membership.

We the undersigned who are financial members of the Club, certify that we know the applicant personally and recommend him/her for membership.

PROPOSER: I have known the applicant ______ years ________________________________

SIGNATURE of Proposer (Print name and membership No):__________________________________

SECONDER: I have known the applicant for ______  years______________________________

SIGNATURE of Seconder: (Print name and membership No:____________________________________

Office Use:    Date Nomination Received:____________         Date elected / declined________________

Subscription Paid:_$_____________    Receipt No:_____________    Membership No:________________