Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Eligibility Confirmation *

Please confirm that you are a person who owns and/or operates an Amusement Device

Yes

No

Yes Consultant/Developer/Inspector

Undertaking *

As a member of NZOAD I undertake to not undermine the purposes of the Society as set out in the rules at any time, via any medium or action.

Agree

Rules & Subscriptions *

I agree to abide by the rules of the Incorporated Society and acknowledge that if subscription levies are require they must be paid, in full, for the period that they are applicable. Failure to do so may affect my right to vote in any subsequent meetings/ballots etc

Yes

No

Date *

MM

DD

YYYY

Name Publishing Permission *

Are you happy for your company name to be published on this website as a member?

Yes

No