Rakaipaaka Registration

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:

I am 18 years or older

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)

Beneficiary's Full Name:

Fathers Name	Paternal grandfather	Paternal Great grandfather	Paternal Great - great grandfather
			Paternal Great - great grandmother
		Paternal Great grandmother	Paternal Great - great grandfather
			Paternal Great - great grandmother
	Paternal grandmother	Paternal Great grandfather	Paternal Great - great grandfather
			Paternal Great - great grandmother
		Paternal Great grandmother	Paternal Great - great grandfather
			Paternal Great - great grandmother

Mothers Name	Maternal grandfather	maternal Great grandfather	Maternal Great - great grandfather
			Maternal Great - great grandmother
		Maternal Great grandmother	Maternal Great - great grandfather
			Maternal Great - great grandmother
	Maternal grandmother	Maternal Great grandfather	Maternal Great - great grandfather
			Maternal Great - great grandmother
		Maternal Great grandmother	Maternal Great - great grandfather
			Maternal Great - great grandmother