Create Enrolment

Declaration: By submitting this information you confirm that you wish to be included in the Aupouri Beneficiary Roll and the information that you have provided is correct to the best of your knowledge.

Please ensure you click the "Save" button (located on the Marae & Voting tab)

Salutation: *

Ingoa Whanau: *

Surname

Ingoa Tuatahi: *

First Names

Ingoa Takakau:

Maiden Name

Birth Date - Ra Whanau: *

Kainga Noho: *

Address

Phone:

Mobile:

E-mail:

First Name	Last Name	Birth Date (D/M/Y)	Gender
First Name:	Surnames:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:
First Name:	Surname:	Date of Birth: Day: Month: Year:	Gender:

		Great Grandfather:	Great Great Grandfather: Great Great Grandmother:
	Grandfather:	Great Grandmother:	Great Great Grandfather: Great Great Grandmother:
Father:
	Grandmother:	Great Grandfather:	Great Great Grandfather: Great Great Grandmother:
		Great Grandmother:
			Great Great Grandfather: Great Great Grandmother:

		Great Grandfather:	Great Great Grandfather: Great Great Grandmother:
	Grandfather:	Great Grandmother:	Great Great Grandfather: Great Great Grandmother:
Mother:
	Grandmother:	Great Grandfather:	Great Great Grandfather: Great Great Grandmother:
		Great Grandmother:
			Great Great Grandfather: Great Great Grandmother:

Marae:

Other Marae:

Voting Electorate:

Are you adopted or Whangai: *

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