Nomination for Associate Membership Form

Name: Michelle Golder
Email: mgolder@outlook.com
Address: 18 Jellicoe Crescent, Kaikorai, Dunedin 9010
Home: 034672755
Mobile: 0275561394
Occupation: Business Manager
Date of Birth: Array Array, Array Array
Marital Status: Array
Spouse / Partner’s Name: Daniel Marsh
Branch: Navy

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: C1012945
Service: Array
Units: Sonarman/Combat Systems Specialist
Length of Services: 4 years
Rank: ASN
Theatres of Service and Dates: Sept 2001 – Oct 2005
Medals and Awards: NZGSM Afghanistan (secondary) NZOSM
Any other Relevant Services Information RNZN, Served HMNZS Tamaki, HMNZS Philomel, HMNZS Canterbury, HMNZS Te Mana 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