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NZSA Online Corporate Membership Application Form Fields denoted * must be filled; default settings are for change of address   Institution:* Address (for posting journal):*     Country: Web:* Contact Person:* Phone:* Fax: Email:* Permission to publish:     Contact Details in Australia & NZ Members Directory? Yes No     Name, Address, Phone, Fax in Web Directory? Yes No     Email Address in Web Directory? Yes No Please choose membership category from drop-down list. Make cheques out to NZ Statistical Association. (NZSA is not registered for GST.) Membership type:* Choose from drop-down menu Corporate: $160 $ Payment Details, in increasing order of cost to NZSA Please submit electronic form for all methods of payment. Payment by automatic payment or telebank: Please ensure that your name will appear on our bank statement (e.g., Statistics New Zealand) Bank 02 Bank of New Zealand Branch 0500 BNZ Centre, Wellington Account 0019525-00 New Zealand Statistical Association Payment by cheque: Make out to New Zealand Statistical Association (Inc). Payment by Mastercard or Visa: Please supply this information Credit Card number Cardholder's name Expiry date Amount: $NZ The NZSA Email address and Website are not secured sites so confidentiality of credit card email transmission cannot be guaranteed. If paying by credit card, fax or mail hard copy. Signature:   Date: Fax to Harold Henderson +64 (7) 838 5012 or Post to Harold Henderson, Statistics, AgResearch Ruakura, Private Bag 3123, Hamilton, NZ For more information contact Harold Henderson