Membership - Gujarati NZ

Self Declaration *

Membership *

Membership Details Submitted Via *

Primary Contact Name *

First

Last

Phone *

Email *

Email

Confirm Email

Address *

Address Line 1

City

State / Province / Region

Postal Code

Immigration Status *

No. of Family Members # (excluding primary contact) *

Name (Member 1)

Gender (Member 1) *

Email (Member 1)

Phone (Member 1)

Name (Member 2)

Gender (Member 2) *

Email (Member 2)

Phone (Member 2)

Name (Member 3)

Gender (Member 3) *

Email (Member 3)

Phone (Member 3)

Name (Member 4)

Gender (Member 4) *

Email (Member 4)

Phone (Member 4)

Name (Member 5)

Gender (Member 5) *

Email (Member 5)

Phone (Member 5)

Name (Member 6)

Gender (Member 6) *

Email (Member 6)

Phone (Member 6)

Name (Member 7)

Gender (Member 7) *

Email (Member 7)

Phone (Member 7)

Name (Member 8)

Gender (Member 8) *

Email (Member 8)

Phone (Member 8)

Name (Member 9)

Gender (Member 9) *

Email (Member 9)

Phone (Member 9)

Name (Member 10)

Gender (Member 10) *

Email (Member 10)

Phone (Member 10)

Reference

Ref 1 : Name *

First

Last

Ref 1 : Phone

Ref 2 : Name *

First

Last

Ref 2 : Phone

Note / Comment (Optional)

Student ID *

Click or drag a file to this area to upload.

Family Membership *

Price: $80.00

Student Membership *

Price: $30.00

Membership + Donation

I like to make Donation

Donation Invoice

I required donation invoice for tax purpose

Donation Amount *

Please choose Credit Card or Bank Transfer as Payment Method for donation.

Total

$0.00

Payment Method *

Credit Card
Bank Transfer

Credit Card *

Card

Name on Card

The payment for this membership can direct credit to the bank account details provided below.

Bank: 06-0229-0721009-00
Reference: {first_name}
Code: {your-mobile-number}
Particulars: Membership

It is important that the reference, detail, and code fields are completed with their according to
above, your name and the word Membership so that we can record the payment correctly and pass the
information on to the correct book records.

Please attach below payment reference/screenshot before submit this form.

The payment for this membership can direct credit to the bank account details provided below.

Bank: 06-0229-0721009-00
Reference: {first_name}
Code: {your-mobile-number}
Particulars: M+D

It is important that the reference, detail, and code fields are completed with their according to
above, your name and the word Membership so that we can record the payment correctly and pass the
information on to the correct book records.

Please attach below payment reference/screenshot before submit this form.

Payment Reference

Click or drag a file to this area to upload.

Concent *

I have read and agree to the below terms and conditions *

1. By using this website, you confirm that you agree to this website terms of use. If you do not agree, do not use this websites. Please contact Gujarati Pariwar (Waikato) Inc. (GPW) committee via the contact page. You are responsible for ensuring the security of the personal information held on your computer, mobile or other devices.

2. By submitting this online form, you agree to Terms and Conditions of GPW membership.

3. GPW, reserves rights to change these Terms and Conditions without any prior notice.

4. You agree for GPW to use your personal details as per the contact & membership details form for further communication.

5. Please contact the GPW committee via the contact page, should you require a copy of full membership disclosure with information regarding eligibility criteria of becoming member, paying a subscription, and canceling/terminating membership.

6. GPW executive committee reserves the right to decline your membership and its decision will be considered final and no correspondence will be entered into.

7. I agree that I cannot claim back the registration fee I paid under any circumstance.

8. I allows GPW to upload photos online (social media, website etc) for attended events.