(Subsidiary entity of HOPE O TE WAIROA LTD)

Registration Form
Please fill in your Contact Details (Please print clearly)

First Name

Surname__________________________________________

Maiden Name if applicable

Date of Birth____

______

Male

Female

Physical Address

Postal Address
(if different to above)

______________________________________________________________________________

Phone Number

Mobile

Email Address

Occupation

Nga Tipuna Please fill in relevant details below (Please print clearly
G/G Grandfather
Great Grandfather
G/G Grandmother
Fathers Father
G/G Grandfather
Great Grandmother
G/G Grandmother
Father
G/G Grandfather
Great Grandfather
G/G Grandmother
Fathers Mother
(include maiden name)

If you do not whakapapa to Te

Wairoa Tapokorau but consider
you are eligible to register (for
example, as a Whangai) please
provide supporting information
with this registration form

G/G Grandfather
Great Grandmother
G/G Grandmother

G/G Grandfather
Great Grandfather
G/G Grandmother
Mothers Father
G/G Grandfather
Great Grandmother
G/G Grandmother

Mother (include maiden name)

G/G Grandfather
Great Grandfather
G/G Grandmother
Mothers Mother
(include maiden name)

G/G Grandfather
Great Grandmother
G/G Grandmother

Page 1 of 3

TWT Registration Forms Dec. 2015

Children (persons aged 18 years and over should complete their own form)
(Please print clearly)
Names

Date of Birth

Gender Names

Date of Birth

Gender

Hapu / Iwi: Please Name the Hapu / Marae / Iwi to which you affiliate.
Hapu

Marae / Iwi

Hapu

Marae / Iwi

Hapu

Marae / Iwi

Declaration:
I declare that all information on this form is true and correct. I also hereby authorise HOPE O TE WAIROA to collect such
personal information about me as is necessary to support my application

Signature

Printed Name:

Date:

________________________________________________________________________

Signed on behalf of: ________________________________ Relationship: _________________________

Printed Name:

________________________________________________________________________

Privacy Statement
The information you have supplied on this application form will be held on a centralised database under Whanau/Hapu ownership.
Your information will be treated confidentially, no information will be disclosed to third parties without your authorisation except
as required by law or with other organisations representing Te Wairoa Tapokorau interests. You have the right to view your
personal information held on the database, provided by a nominated Whanau / Hapu representative where information may be
amended as need be.
Note: Deliberately providing inaccurate or false information may render your registration form invalid and resulting in your
registration placed ON HOLD for further deliberation with Validation Committee.

Page 2 of 3

TWT Registration Forms Dec. 2015

Registration Validation
Your registration may need to go through a validation process if your name or whanau is unfamiliar to Whanau/Hapu and / or
Marae / Iwi.
This will involve members of a validation committee reviewing your application details where further decisions may be provided
to ensure your application is processed.
Whanau who do not know their Hapu / Marae / Iwi with what information you provide us, we are confident we can provide you
assistance and guidance in where your inherent interests lay.
Registration for a Checklist
Minimum Requirements

Incomplete Forms

First Name
Last Name
Date of Birth
Address
Signed by Applicant

If the form does not meet the minimum requirements then the form is
deemed to be incomplete, which is then forwarded to Work in
Progress committee.
Remedy the details on the form can be entered into the database,
however cannot be registered.
Communication between the Applicant and the Work in Progress
committee will hopefully ensure registration to be confirmed as
accepted.

Private Notice Option

Tick the box if you wish to receive private notice relating to general meetings and postal ballot papers so that you may vote on
elections, constitutional amendments and/or discussions around fisheries settlement assets.
The notice will be sent to the address provided on this form and it is your responsibility to ensure that Te Wairoa Tapokorau has up
to date contact details for you.

For Further Information Contact

Esther Hakopa-Foster
HOPE O TE WAIROA
PO Box 24
Wairoa 4160
Hm:
(06) 8386053 (PLEASE leave a message)
Mob: 0274487466
Email: hopeotewairoa@gmail.com (interim)

Office Use Only

Date Entered _____________________________________ Date Registered

________________________________________

Tuhono ID _______________________________________ Entered By

_______________________________________

Verification of Information
1.

Printed Name

___________________________________

Signature ________________________________

2.

Printed Name

___________________________________

Signature ________________________________

3.

Printed Name

___________________________________

Signature ________________________________

4.

Printed Name

___________________________________

Signature ________________________________

5.

Printed Name

___________________________________

Signature ________________________________

Approved

Not Approved

Comments
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Page 3 of 3

TWT Registration Forms Dec. 2015