25 Wellington Street, HOWICK
ph (09) 534-9702

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Application For Couples Association

(2 PEOPLE LIVING AS A PARTNERSHIP AT THE SAME ADDRESS)


Name:


Date of Birth:


Email Address:


Name:


Date of Birth:


Email Address:



Address:


Post Code:


Telephone Number:


Work Number:



Has either person been refused or had your membership revoked from any other Club?


Yes
No


If yes, name of Club and details:



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




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