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Registration Form

Nau mai, haere mai

Registration Details

* = Required Field

Email: *

Personal Details

Title: *

First Name: *

Middle Name(s):

Last Name: *

Alias or Nickname:

Maiden Name:

Date of Birth: *

Gender: *

Male Female

Whangai:

Address Details

Street Address: *

Address Line 2:

City: *

Post Code:

Country: *

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Postal Address

Postal Address:

Address Line 2:

City:

Post Code:

Country:

Contact Number:

Mobile Number:

Work & Education

Current Occupation:

Highest Qualification:

Work Experience:

Education Description:

Te Reo Maori Level:

Whanau & Tupuna

Father: * Add Parents

Grand Father: Add Parents

Great Grand Father:

Great Grand Mother:

Grand Mother: Add Parents

Great Grand Father:

Great Grand Mother:

Mother: * Add Parents

Grand Father: Add Parents

Great Grand Father:

Great Grand Mother:

Grand Mother: Add Parents

Great Grand Father:

Great Grand Mother:

Nga Tamariki

Children:

Child

Male Female

First Name:

Last Name:

Date Of Birth:

Whangai:

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Add another child

Child

Male Female

First Name:

Last Name:

Date Of Birth:

Whangai:

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Hapu/Iwi Options

Hapu / Iwi:

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Marae Options

Marae:

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Takiwa / Taiwhenua

Primary Takiwa:

Affiliated Takiwa:

Other Affiliations:

Privacy Details

Yes No

Do you wish to receive information relating to general meetings and postal ballot papers so that you may vote on elections, constitutional amendments, conversion or disposal of settlement quota. Being on the register is very important because it is our main contact link with you and gives you a direct say in decisions that affect you and your whanau. *

Yes No

To keep you informed, do you agree for your contact details to be forwarded to your Takiwa/Taurahere. Please note that any vote casted by you for election of trustees will be counted only for the Primary Takiwa/Taurahere you have identified. *

Yes No

Do you want to be on e-mailing list? *

Declaration Notice

I hereby declare that the information in this application is true and correct to the best of my knowledge. I understand that the information I provide will be used soley for the purpose of Nga Potiki a Tamapahore Trust Board in developing their Register of Beneficiaries, a required Statutory Legislation. The board will deal with this personal information in accordance with its obligations under the Privacy Act 1993 and the Privacy Principles stated therein. I will contact the Trust Board should my details change in the future.

I Confirm that I have read and agree to the Declaration Notice on this application form. *

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