I/We wish to apply to be elected/renewed as member/s of the Canterbury Citroën Car Club and agree to abide by the Club rules (and those of the CCCNZ, to which this club is affiliated.)
In accordance with the Privacy Act 1993 I/we acknowledge my/our right of access to, and correction of this information.

Signature:    .............................................................................................................................

Names

First Name

Last Name/Surname

Name

.

.

Partner/Spouse

.

.

Dependants/Others

.

.

Street:

Residential

Postal: (if different from residential)

Suburb:

.

.

City/Town:

.

.

Occupation: (requirement of Incorporated Society Act) - CCCNZ

Details of Citroën/s Owned

Model type

Year

Registration

Colour

km/mls

1.

.

.

.

.

2.

.

.

.

.

3.

.

.

.

.

Phone :

Fax

Email

Privacy Act. I/we agree to having my name, address, contact details and car ownership information published in a list available only to other Citroën Car Club members, and in the National Citroën register published from time to time.

YES................................................. NO...............................................(circle intention and add your signature)