Membership Registration – Dutch Club Wellington

Member Registration Form

Single Person membershipFamily membership

First Name*

Last Name*

Birth Date*

Partner's First Name*

Partner's Last Name*

Partner's birth date*

Names and ages of children below 16 years

Children's birth date*

We will use your birth date to congratulate you in the Double Dutch edition that covers your birth month. Your birth day will not be published.

I am OK with that.I don't want to be congratulated in the Double Dutch.

Street Address*

Suburb

City & Postal Code*

Please note that only family members that live at the above address are included in this family membership.

Contact Telephone Number*

Email Address*

How would your like to receive our magazine?

Printed CopyElectronic Copy

Membership Payment

I have transferred the membership fee to your bank-accountPlease contact me about membership payment

Only fill in if you are not human