Associate Member Application Form

Name(Required)

Title First Name Last Name

D.O.B(Required)

Address(Required)

Street Address Suburb

Postal Address Checker

Postal Address (If different from above)

Postal Address(Required)

Street Address Suburb Postal Code

Please check the box if you do NOT want to receive emails/offers from Henderson RSA

Phone (Home)

Phone (Work)

Phone (Mobile)(Required)

Email(Required)

Occupation(Required)

Details of membership at any other RSA

Declaration(Required)

I agree to the declaration of consent

I, the Applicant, understand that I must abide by all of the rules and regulations of Henderson RSA and that any false particulars given here may invalidate my membership. I also declare that I have not had disciplinary action taken against me by another club and that I am happy to pass on my personal details to the RNZRSA and Clubs New Zealand whom the club and its members are also associate members of.

Please note: MEMBERSHIP RENEWALS START FROM 1ST OF NOVEMBER EACH YEAR, WHICH TAKE YOU THROUGH TO 31ST DECEMBER THE FOLLOW YEAR.

AFTER RENEWING YOUR MEMBERSHIP, PLEASE PICK UP YOUR NEW MEMBERSHIP SUBSCRIPTION STICKER FROM THE BAR AND STICK IT ONTO YOUR MEMBER CARD.

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