Name:

................................................................

Address:

................................................................

................................................................

................................................................

Phone:

........................... Fax: .............................

Email:

...................... Occupation: ......................

Sub:

Single: $20.00 / DOUBLE $25.00

Enclosed:

$............................................

I agree to the following details being published in the Newsletter
and/or Website, and my details being available to people wanting to
contact Kunekune owners in their locality (Tick all that you agree to.)

NAME --- ADDRESS --- PHONE --- EMAIL

Signed:

................................ Date: .....................