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NZ Medicinal Cannabis Club Incorporated.

MEMBERSHIP APPLICATION.

NB: Membership is by DONATION. You decide how much you can afford or how much you support this issue.

COMPANY / INDIVIDUAL NAME:

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ADDRESS:

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CITY / TOWN: _____________________________

POSTCODE:_________PHONE:_________________FAX:__________________EMAIL:___________________

ELECTORATE:___________________________________

CURRENTLY INVOLVED IN: ___________________________________________________________________

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I/WE CAN ASSIST THE NZMCC RE:_____________________________________________________________

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MEMBERSHIP From August1st Annually.

I wish to donate only to the NZMCC. I do not wish my name and or address to be recorded. __ Please tick one.

I wish to be a member/supporter. I am comfortable for my details to be kept confidentially by the NZMCC. __

Bankers: National Bank,Wellington, Johnsonville Branch. A/c NZ Medicinal Cannabis Club Inc. account number 06-0541-0150175-00

NEW ZEALAND MEDICINAL Cannabis Club INCORPORATED. 2000.

P.O. Box.