I wish to enrol as a member of the Post Polio Support Society of New Zealand Incorporated. The annual subscription is due each July 1st.

SURNAME: Mr Mrs Miss Ms Dr
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FIRST OR PREFERRED NAME:
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POSTAL ADDRESS:
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_________________________________________________________________Postal Code:______

PHONE NUMBER: (0 __)__________________E-mail____________________________

Date of Birth:_____/_____/______

YEAR IN WHICH YOU CONTRACTED POLIO: 19_____ LOCATION IF NOT NZ:___________________

Signature:_______________________________________________________

Please print out and post this application form and membership fee to Post Polio Support Society of NZ Inc., P.O. Box 249, Oamaru 9444