Tour

Section 1: Personal Information

	Applicant		Partner
Surname		Surname
First Name		First Name
Email		Email
Date of Birth		Date of Birth
Address		Address
Phone (Home)		Phone (Home)
Phone (Business)		Phone (Business)
Fax		Fax
Occupation		Occupation
Hobbies & Interests		Hobbies & Interests

Section 2: Club Information

Club Name

Number

Association

Section 3: Registration Fee

Registration (NZ $1500 p.p)

NB: After filling in this form you will be given the option to pay for your tour via PayPal using your PayPal account, or Credit card.

Alternatively payment can be made by direct credit to the NEVILL BULLOCK RTNZ CHARITABLE TRUST bank account at the BANK OF NEW ZEALAND, CHRISTCHURCH BRANCH, HEREFORD STREET, CHRISTCHURCH. Account no. 020800-0465439-00 Swift # BKNZ NZ 22 800

All payments must be in NZ currency

Section 4: Indemnity Disclosure

All travel to and from and during the Nevill Bullock RTNZ Charitable Trust 2011 Tour, and all other activities undertaken during the tour, are undertaken entirely at my own risk and the risk of those accompanying me. No member of Round Table New Zealand, or member club, or the National Association of Round Table of New Zealand Incorporated, and no Trustee of the Trust or the Nevill Bullock RTNZ Charitable Trust itself will have any liability to me or any person accompanying me for any loss or damage of any nature whatsoever which I or any person accompanying me may incur and however that damage or loss may arise while en route to or during the tour or in connection with any activity on the tour.

I understand and agree to the Indemnity disclosure above.