Nomination for Associate Membership Form

Name: Logan Makiiti
Email: logan.makiiti@gmail.com
Address: 72 Gilkison street halfway bush
Home: 0275233267
Mobile: 0275233267
Occupation: Brewery Technician
Date of Birth: Array Array, Array Array
Marital Status: Array
Spouse / Partner’s Name: Jo-Ann
Branch:

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: Q1019121
Service: Array
Units: Philomel, Hinau, Te Mana, Canterbury
Length of Services: 6years, 1month
Rank: ASCS
Theatres of Service and Dates: Persian Gulf, 2008.
Medals and Awards: OSM, GSM (AFGAN SECONDARY) RSM
Any other Relevant Services Information N/A Are you receiving any financial assistance from War Pension Services? Array
Would you like the RSA Welfare Officer to contact you? Array

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