Please highlight then print out this form. If you have trouble, e-mail bike-italian@xtra.co.nz for a form file.

Italian Motorcycle Owners Club (Inc), PO Box 68-292, Newton, Auckland, NEW ZEALAND

Membership 30 Nov. 2009 – 30 Nov. 2010

First name: ______________________ Surname: ______________________

If filling out this form for a couples membership (a couple who are both IMOC members), please add the name of the second person below.

First name: ______________________ Surname: ______________________

Home telephone no. _____________ Cell phone: _______________________

E-mail address: _________________________________________________

Postal address: _________________________________________________

______________________________________________________________

Motorcycle(s) owned:_____________________________________________

 Do you want a printed copy or electronic version (PDF) of the club magazine Motociclismo?

I want a printed copy [   ]                    Send a  PDF file to my e-mail address [   ]

_________________________________________________________________

Optional – Next of kin to contact in event of accident or other reason.

Name:  ______________________________________    

Phone: (       ) ______________________

Membership Fees

Full year (30 Nov. 2009 to 30 Nov. 2010)

Single $45 [   ]       Couple $55 [  ]                                              Cash [  ]     Cheque [  ]

Please make cheques payable to:  Italian Motorcycle Owners Club, and post to:

PO Box 68-292 Newton, Auckland

I/We hereby agree to abide by the rules set out in the constitution of the Italian Motorcycle Owners

Club NZ (Inc) and not to hold the club or any of the officers of the club responsible for any damage or

injury during any club activities or events.

Signed                                Date ________________________

Consent under the Privacy Act 1993

The Privacy Act 1993 requires that the Italian Motorcycle Owners Club (Inc), as an agency collecting

personal information, discloses:

1. That the information is being collected.

2. The purpose it is being collected for, which is for administrative purposes, to enable completion of a 

      mailing list to circulate information and to assist in the proper management and conduct the affairs of the club.

3. That the recipients of the information will be the Italian Motorcycle Owners Club (Inc).

4. That each person has the right to assess their personal information and request correction of the information.