PIBBA Membership Application


	22 Fergusson Street, Mangere, Auckland, New Zealand. Membership Application
Name
Address
Phone
Mobile
Date of Birth	/ / 19 (day/month/year)
Age	years old
Gender	Woman	Man
Height	metres
Weight	kilograms
Previous Titles
Ethnic Group (tick one)	N.Z. Maori Cook Island	Samoa Tonga	Fiji Niue Other
Membership & Entry Fee	Paid	Unpaid
Date	/ /	Signature