Then Mail the completed form with remittance to SeniorNet Papakura Inc PO Box 72 427 Papakura 2244

Name/s____________________________________________________ Membership No:_____________

Please update your Postal Address_______________________________Post Code______________

Please update your Email Address________________________________

Please update your Phone #____________________

� I / we wish to renew our membership 1/03/2017 to 28/02/2018

� Cheque is enclosed for $30 single / $50 couple. Please indicate applicable fee.

� Internet Banking Account 12-3031-0270787-00. Ensure you enter your name in the detail.

� I / we do not wish to renew the membership and resign

If resigning, may we know why?________________________________________________________

_______________________________________________________________________________________

SIGNATURE___________________________ DATE_____________________