Office Use Only

Date:......................
Receipt No:...............
Card/s Issued:...........
Actioned By:..............

Nelson Grey Power Membership Form

Print this form and post with your subscritption to
Nelson Grey Power P O Box 2190, Stoke. Nelson

Mr/Mrs/Ms/Miss

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Address:

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Phone No:.....................

Date/s of Birth:..........................

Email Address
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Would you be interested
in helping in our Office Yes / No

Subscriptions
Please note:-
Subscriptions run from 01 April to the 31 March

Couple: - $25 Single - $15
Circle One

Send to: Nelson Grey Power, P O Box 2190 Stoke, Nelson
Please make your cheques payable to: Nelson Grey Power

Do you want promotional material
from other companies sent to you
Yes / No

Please sign to show that you agree to support the objectives of Grey Power
i.e Protecting the rights of senior citizens and others over 50 yrs

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