Application To Join

SeniorNet Porirua

Personal Details

Current member          Yes               No
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Name:____________________________________________________________________
         Ms/Miss/Mrs/Mr             Preferred first name                          Surname

Address: _______________________________________________________
               Number         Street                                    Suburb        City Post Code

Phone: _________________

E-mail: _______________________________
If applicable

Age Group:            50 - 59                                     60+
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Ethnicity:

                            European          Maori           Pacific Islander            Asian

Other Please tick or specify here _________________________________
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Nationality:                 New Zealand Citizen                         Other
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Questions for new members:

How did you learn about SeniorNet Porirua?

City Life     Northern Courier    Friend       
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Other (please specify)_________________________________

Home Computer:

      I Have a PC at home      I'm about to purchase one           I Have an Apple Mac
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Signed: _______________________________