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TAPUIKA ENROLMENT APPLICATION

APPLICANT DETAILS

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Surname

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Maiden Name

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First Name(s)

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Gender

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Date of Birth (dd / mm / yyyy)

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Home Phone

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Work Phone

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Mobile Phone

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Email

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Address

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Postal Address

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WHAKAPAPA – To be completed by those applicants of Tapuika descent. Select hapu as applicable below

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TUHEKE

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MOKO

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MARUKUKERE

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KURI

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UNKNOWN

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WHAKAPAPA – To be completed by those applicants NOT of Tapuika descent. Select relationship as applicable

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Please list your Iwi

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WHAKAPAPA - Father

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Paternal Grandfather

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Paternal Grandmother

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Mother

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Maternal Grandfather

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Maternal Grandmother

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I confirm the information given in this form is true and accurate and that I have read the Privacy Act Disclaimer below

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I am responsible for communicating any change to my personal details (e.g. change of address)

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SIGNED

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Please tick if including dependant/s listed below. (only include those children under the age of 18 years)

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CHILD / DEPENDANT #1 - Name:

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Gender

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Date of Birth ( dd / mm / yyyy)

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Other Parent

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Whangai?

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CHILD / DEPENDANT #2 - Name

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Gender

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Date of Birth ( dd / mm / yyyy)

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Other Parent

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Whangai?

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CHILD / DEPENDANT #3 - Name

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Gender

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Date of Birth ( dd / mm / yyyy)

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Other Parent

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Whangai?

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CHILD / DEPENDANT #4 - Name

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Gender

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Date of Birth ( dd / mm / yyyy)

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Other Parent

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Whangai?

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CHILD / DEPENDANT #5 - Name:

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Gender

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Date of Birth ( dd / mm / yyyy)

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Other Parent

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Whangai?

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CHILD / DEPENDANT #6 - Name

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Gender

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Date of Birth ( dd / mm / yyyy)

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Other Parent

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Whangai?

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CHILD / DEPENDANT #7 - Name

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Gender

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Date of Birth ( dd / mm / yyyy)

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Other Parent

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Whangai?

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CHILD / DEPENDANT #8 - Name

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Gender

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Date of Birth ( dd / mm / yyyy)

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Other Parent

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Whangai?

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PRIVACY ACT DISCLAIMER This form is for registration as a member of both Tapuika Iwi Authority and Tapuika Fisheries Trust and is subject to the Privacy Act. Any personal information provided will only be disclosed for the purpose of Treaty settlement negotiations, Fisheries and communication on Iwi matters

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OFFICE USE ONLY - Date Received

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OFFICE USE ONLY - Date Verified

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OFFICE USE ONLY - Kaumatua sign

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Mandatory fields exist within this document please ensure all required fields are complete above

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