HOME                                 HUNTLY & DISTRICTS WORKINGMEN’S CLUB

                                                       MEMBERSHIP NOMINATION FORM

                                                                             

Mr., Mrs., Miss, Ms

 

FIRST NAME: _______________________________________________________                              

 

SURNAME: _________________________________________________________

 

OCCUPATION:__________________________________________________________

 

Nominee to complete

 

Address of Nominee

 

____________________________________________

 

Email:________________________________________

 

Phone No:____________________________________

 

Cell:_________________________________________

 

Date of Birth:___/______/_______

  

 

Your address, phone no and date of birth details are required to process your membership.  These details will not be displayed on the membership board.

 

Nominee to complete(Please fill out this section)

Have you ever been refused membership or expelled from any Chartered Club?  YES/NO

If YES, please advise name of Club and full details:

Have you ever been convicted of any crime within the Crimes Act?  YES/NO

Are you a New Zealand citizen?  YES/NO

 

·       Enclosed is my nom fee of $10.00.

·       If accepted as a member I promise to pay the subscription due to my membership expiry date.

·       I further promise to abide by the Rules and Constitution of the Club.

·       I certify that all the information supplied is true and correct.

·       I authorise the Club Executive Committee to make any additional enquiry to establish my suitability as a member of this Club.

 

Signed                                                             Date

 

 

 

Please fill in form and bring into the club.