Membership Application

Contact details

Title

First Name*

Last Name*

Date of Birth (dd/mm/yyyy)*

Occupation

Payroll No

Station

Watch

Home Phone

Work Phone

Cell Phone*

Email*

Postal Address 1*

Postal Address 2

City*

Street Address 1

Street Address 2

City

Nominated next of kin

Name*

Relationship to You*

Address 1*

Address 2

City

Day Phone*

Night Phone

Funeral benefit payment instructions

(Persons to whom you instruct us to pay the Funeral Assistance Benefit in the event of your death)

Name*

Date of Birth (dd/mm/yyyy)*

% of Benefit to Receive*

Contact Details*

Name

Date of Birth (dd/mm/yyyy)

% of Benefit to Receive

Contact Details

Name

Date of Birth (dd/mm/yyyy)

% of Benefit to Receive

Contact Details

Name

Date of Birth (dd/mm/yyyy)

% of Benefit to Receive

Contact Details

How did you hear about us?

Terms & Conditions* I agree to the Terms & Conditions

Tick this box to prove you are a human.*

NZ Firefighters' Welfare Society

Membership Application