SENIOR INTERMEDIATE MEMBERSHIP RENEWAL FORM

SENIOR INTERMEDIATE MEMBERSHIP RENEWAL FORM

Please fill out form correctly
SENIOR INTERMEDIATE MEMBERSHIP IS 17-21 YEARS OF AGE ONLY

If you are 21 years or older please exit this form and fill out the senior membership form.
Senior Intermediate Membership $65.00
Membership Renewal or New Membership
Name*
Postal Address*
Phone Number*
Email*
example@example.com
Date Of Birth *

MonthDayYear
DOB
Male / Female *
Membership Type *
Do you need a new card
PLEASE ONLY FILL OUT NEXT SECTION IF YOU ARE PAYING WITH CREDIT CARD -
Please Select & Enter Quantity *
prevnext( X )
SENIOR INTERMEDIATE MEMBERSHIP Please Note* A credit card fee has been added
$66.97NZD Quantity

Total

$0.00NZD
Additional Comments
DECLARATION

I declare that the above information is correct. I agree to abide by the Club Rules & Constitution through my entire duration of membership to the Whangarei Deep Sea Anglers Club Inc

ANNUAL MEMBERSHIPS ( 1st OCTOBER - 30th SEPTEMBER )
By selecting YES I declare that the information provided is correct & agree to the declaration above.*

YES
Should be Empty:

SENIOR INTERMEDIATE MEMBERSHIP IS 17-21 YEARS OF AGE ONLY