Text Box: SeniorNet Palmerston North Inc. Application for Membership Surname ____________________________________________ First Name ____________________________Mr. Mrs. Miss Ms Address ____________________________________________ _____________________________Post Code_______ Phone number __________________________ E-mail address ____________________________________________ Essential Information: Which of these Operating Systems & Programs do you have on your computer? Windows XP_______ Windows Vista _______ Windows 7_______ Microsoft Word 2003 ________ Microsoft Word 2007 _________ Please complete the following information by indicating which area is applicable:- This information is required as a Governmental Funding requisite Age: 50-59….…..60+…..….Permanent NZ Resident: Yes/No…..…. European:…….. Maori:…….. Pacific Island:…….. Asian:…….. I certify that I am 50 years or over and I agree to my personal details being entered into SeniorNet’s data base. Signed______________________________ Date ________________ ********************************************************* OFFICE USE ONLY Subscription Payable $______ Date __________ Receipt No.________ Worsfold. File_________ New Memb List_________ Nametag _______ Address Book______Email Group_______SeniorNet Memb Group______ Email Sent_______ January 2010 Text Box: SeniorNet Palmerston North Inc. Application for Courses Course applied for: - ___________________________________ Surname__________________________ First Name ________________________ Mr. Mrs Miss Ms Telephone ______________ E-mail _______________________ Preferred Day _____________ Preferred Time ______________ Would you accept a change? Yes / No Do you need a disability carpark? Yes / No Essential Information: Which of these Operating Systems & Programs do you have on your computer? Windows XP________ Windows Vista__________ Windows 7_________ Microsoft Word 2003___________Microsoft Word 2007__________ Day _________ Date __________ Time _____________ Fee Paid:- $ ___________ Receipt No: ___________ Authorising Officer_________ Course Code________________ January 2010

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