Membership - ACE Aotearoa 2018 Form

Membership Form January to December, 2018

ACE Aotearoa Membership Application 2018

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* 1. Contact Information

First Name

Surname

Organisation

Job Title

Postal Address

Post Code

City

Contact Phone Number

Email Address

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* 2. Membership Categories: (please fill out a separate form for each membership)

Part time Waged / Unwaged Individual : $25

Full time Waged Individual $50

Organisation/Group* : $50

*How many people are represented by this organisation?

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* 3. Donation / Koha

Amount

Total to Pay (including membership)

Note: Amounts are GST incl

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* 4. Payment Method (select one)

Cheque – Please make cheque payable to ACE Aotearoa

Electronic Bank Transfer
Bank Account name: ACE Aotearoa
Bank Account number: 02 0585 0059963 000

Please include your name or your organisation’s name, and put “Membership 2018” as the reference

All payments are due by Wednesday 28 February 2018.

I/We agree that membership of ACE Aotearoa allows the information on this application form and associated documents to be used by the association and its branches in accordance with the provisions of the Privacy Act 1993.

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* 5. Agreement

Yes

By submitting this form, you acknowledge that you agree to the terms and conditions of the ACE Membership