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Palmerston North Cosmopolitan Club Membership Form
All fields marked with
*
are required.
Full Name
*
Email Address
*
Mobile Phone Number
*
Home Phone Number
Date of Birth
*
Gender
*
Gender
Male
Female
Occupation
*
Full Residential Address
*
*
*
Membership Type
*
Please choose one of the following:
I HAVE had a criminal conviction within the past five years
*
I HAVE had a criminal conviction within the past five years
Yes
No
I HAVE been rejected or expelled from another club
*
I HAVE been rejected or expelled from another club
Yes
No
If any false information is supplied, cancellation of membership is automatic.
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