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Membership Application Form

Name *
Street address*

Town/City*
email address*
Contact Phone number*
Alternative Phone
Occupation(s)*
(NZ law for incorporated clubs & sociteties requires us to collect occupation information)
* required field
Vehicle Details :

Model
 Type
 Year
 Reg. no.
1
2
3

I/we wish to apply for:
Standard
Subscription
rate
Individual Member
Family Membership
Country Member
Family Membership (country) 		$37
$39
$32
$34
Half rates apply if joining between 1st Jan & 30th June. Payments can accepted by cheque or by electronic transfer. (Account details will be sent on receipt on membership application)

I/we would like to receive club newsletters by
Post
Email
Both
Privacy Policy : Personal information supplied to the Peugeot Car Club (Wellington) Inc will be securely held by the club for administrative purposes and not divulged to third parties without your consent. Personal information held is available for inspection and correction.