Please fill the registration form as accurately as you are able. Dates would be appreciated. If there is more to add to this form, please do not hesitate to email us - admin@rakaipaaka.co.nz  We are always available to answer all questions.
Application for Beneficiary Roll Registration
I hereby apply to have my name entered on Te Iwi o Rakaipaaka Inc. Beneficiary Electoral Roll and declare the following statements to be true to the best of my knowledge and belief.
Surname:	*	Full Christian Name:	*
Residential Address	*
Email:	*	Phone:	*
Iwi		Hapu:
Sex:	Male Female	I am 18 years or older	yes no
Marital Status:		Your Date of Birth:	dd/mm/yy
Spouses Name:		Spouses Date of Birth	dd/mm/yy
District you have resided for the last three months in:
Occupation/Skills:
Children Details:
Names of Children Date of Birth Address:
Mokopuna
Names of Children Date of Birth Parents Name Address:

WHAKAPAPA

Beneficiary's full name and name of both parents should be given (birthdates would be appreciated)