Application To Join RTNZ Nevill Bullock Tour

	Applicant		Partner
Name: Surname
First Name:
Date of Birth:
Address:

Home Telephone: (include area codes)
Business Telephone:
Fax:
Email:
Club Name:		No:	Association:
Occupation:
Hobbies & Interests:
Completed application may be faxed, but please post original along with photos, Thank you.
Registration:	NZ $950 p.p.		$
Payment is to 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
INDEMNITY DISCLOSURE All travel to and from and during the Nevill Bullock RTNZ Charitable Trust 2010 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.