Graduate Women Wellington
New Zealand Federation of Graduate Women Wellington Branch
PO Box 2006
Wellington 6140
www.graduatewomenwellington.org.nz
MEMBERSHIP APPLICATION FORM
for the year 1 JULY 2015 – 30 JUNE 2016
SURNAME:
Surname
FIRST NAME(S):
First name(s)
TITLE:
Dr, Miss, Ms, Mrs, Prof, Rev, Hon or Dame
ADDRESS:
Street address
Suburb
City
Postcode
EMAIL:
email address
PHONE NUMBER(S):
Phone number(s), including mobile phone number if available
DEGREES/DIPLOMAS
Qualification
Qualification name
Qualification name
Qualification name
Qualification name
Date awarded
Date/Year awarded
Date/Year awarded
Date/Year awarded
Date/Year awarded
University
University name
University name
University name
University name
OTHER DISTINCTIONS:
Insert other distinctions
CURRENT OCCUPATION:
If you wish to share your current occupation, please include
SPECIAL INTERESTS:
Add special interests here
Signature:
Do you require a receipt?
Date: Select date
☐
Branch subscription is $65 for Graduate members, $60 if paid by 30 September 2015
(Graduate subscriptions include capitation payments totalling $50 approximately to NZFGW and GWI)
Payment options:
PLEASE DO NOT PAY OVER THE COUNTER AT A WESTPAC BRANCH
Cheques to be made payable to:
NZFGW – Wellington Branch Inc
Post this form with payment to:
Treasurer, Graduate Women Wellington
PO Box 2006, WELLINGTON 6140
Pay by Direct Credit to:
NZFGW – Wellington Branch Inc
Westpac account number: 03 0518 0180237 00
Please enter your name and Sub 15.16 in the reference fields
Email completed form to:
membership@graduatewomenwellington.org.nz