Nomination for Associate Membership Form

Name: Michael John Ferguson
Address: 19 Orme St , Outram, Dunedin
Home: 034861515
Mobile: 0274369344
Occupation: Retired
Date of Birth: October 11, 11 1954
Marital Status: Married
Spouse / Partner’s Name: Colleen Bellamore
Branch: Dunedin

Declaration: I hereby apply for membership of the Dunedin Returned and Services’ Association
and certify that the information given herein is correct. I undertake to abide by the Constitution
and Rules of the RSA. I have never been expelled or rejected from membership of any other
branch of the Returned and Services’ Association organisation.


Proposition:We, the undersigned, being financial members of the Dunedin Returned and
Services’ Association, hereby nominate the above named Returned Serviceman/Servicewoman
for membership of the association. We believe this person to be a fit and proper person,
possessing the necessary qualifications for membership.

Proposer: How long have you known the applicant? __________________ years
Proposed by: ____________________ Signed:________________ Date: ________________
Seconder: How long have you known the applicant? __________________ years
Seconded by: ____________________ Signed:________________ Date: ________________

RSA Returned / Service Application

Service Number: X44871
Service: Army
Units: RF Cadet School, Waiouru. 3 Inf Workshop Burnham and Dunedin
Length of Services: 7 yrs
Rank: Cpl
Theatres of Service and Dates: 08 Jan 1971 to 01 Oct 1977
Medals and Awards: nil
Any other Relevant Services Information 3 Star Ve4hicle mechanic Are you receiving any financial assistance from War Pension Services? No
Would you like the RSA Welfare Officer to contact you? No

Committe use only

Date application received: __________________________
Committee Members to Initial: 1.) ______________ 2.) ______________
Accepted/Declined Accepted/Declined
(delete as applicable) (delete as applicable)

Committe use only

Letter sent date:________________
Amount due: ______________ Amount Payed: ______________ Date: _______________
Card Number: _______________________ Card and Badge sent date: _______________ (if applicable)

Copy to Welfare Officer date _______________ (all successful applications)
Application complete – Secretary signature ____________ Date ____________

Please return to P.O Box 4008, St Kilda, Dunedin