Name

First Name

Last Name

Whanau Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

Country

(###)

###

####

Cell Phone

Country

(###)

###

####

Date of Birth

YYYY

Occupation

Work Phone

Country

(###)

###

####

Would you like a more active role with regards to your area of interest?

Yes

Would you like to receive the monthly panui from Runanga?

Yes

Would you like to receive the monthly runaka minutes?

Yes

Are you currently registered with Ngai Tahu?

Yes

If yes, please state your 1848 Kaumatua Name and Number:

This is necessary to complete registration

Partners Details

Full Name, Tribal Affiliation, Occupation, Date of Birth

Details of dependants living with you

Name, date of Birth, Occupation, Where

Details of Children not living with you

Name, address, date of Birth

Any other details of requests