Membership Form. Page 1 of 5. am / was a member of Mensa NZ Membership number (if known) Approximate date of joining... Previous name (if different)

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1 I I I Membership Form am / was a member of Mensa NZ Membership number (if known) Approximate date of joining... Previous name (if different) MENSA NEW ZEALAND Inc. PO Box 5765 Wellesley Street Auckland 1141 New Zealand enquiries@mensa.org.nz Ph: (09) Member Society of Mensa International passed my supervised test but did not join at the time, approx. date of test: am / was a member of another Mensa national group.. Country.. Membership number (if known)... Previous name (if different) Please complete the information below for our records. Title Name Address e.g. Ms, Mr First name(s) Known as (e.g. Max ) Last name No. and street Date of birth / age Phone numbers address Suburb Town / City Province / Area Postcode Day / Mth /Year Hm / Wk and Mobile / / / Mob: Gender Please circle M F Page 1 of 5

2 Membership Fees tick where applicable 1 year to 30 th June 3 years to 30 th June Annual Membership $45 $120 Additional Family Member $30 $80 Student / Unwaged / Senior (enclose copy of evidence ID) Mensa Membership Card (Discounts and Special offers included) $30 $80 Mensa Pen Quantity $2.50 Mensa Certificate $10 Mensa NZ History booklet $5 Overseas Resident Mensa Address your.name@members.mensa.org.nz Mensa Register Listing (profile optional) Mensa Magazine Menzed Electronic Add for postage Yes / No $15 Mensa NZ Online Website / Forums Register International Mensa Forums Register Payment Options: please tick method used By cheque to the PO Box address below By direct credit to BNZ account (Make sure to include your membership number and surname in the payment details.) Send this form to the Membership Officer Mail PO Box 5765, Wellesley St, Auckland 1141 or to: membership@mensa.org.nz Important: Remember to inform the membership officer of any changes to your contact details. membership@mensa.org.nz Page 2 of 5

3 Information about some optional benefits with your membership. Please supply Menzed to me as a paper copy instead of a PDF. Yes Yes, I d like $2.50 each Yes I would like an alias My existing address (to forward to) Yes, I d like.. $5.00 each. Menzed - National newsletter. This is sent out eleven times a year (a double issue in December/January). If you wish, you can receive it as a printed copy (generally in black and white, though) instead of a PDF. Name and Address Listing All Mensa members are listed in the address listing which is distributed to members once a year. If you request, your contact details can be excluded, and only your name and area will appear. Tick here if you do not want your contact details published in the address listing. Mensa Certificate $10.00 The A5 size certificates are attractively printed with your name and membership number on marble effect card with gold embossed Mensa logo signed by the current Chairman.Frame one and hang it on your wall! I would like to purchase a certificate for $ My name as I would like it to appear on the certificate: Mensa Pen $2.50 Ballpoint pen printed with black Mblem, Mensa NZ web address and It s more than you think Mensa Address (free) A mensa.org.nz address is available for all members e.g. yourname@members.mensa.org.nz Mail sent to your Mensa address will be forwarded to your regular mailbox. The Mensa address I d like Mensa New Zealand 1966 to 2006 $5.00 A history of the first 40 years of Mensa in New Zealand, told as memories of members, including a few of the founder members. A few colour photos of recent and past members. Mensa NZ Online Forums (free) These provide an opportunity for discussion and idea sharing among Mensa NZ members. Registration is available via the Members page of International Mensa Online To access the huge range of forums available to Mensans on the International website and Mensa America site contact Submit your particulars and your Mensa New Zealand number. You will be welcome on the SIGs and there is a vast list of SIG addresses. An international list of esigs are obtainable along with a library of the many National magazines from countries around the world plus much more. Page 3 of 5

4 Register of Members Distributed to members every months is the Register of Members. This helps members know a little more about each other. Inclusion is voluntary and contains whatever information members wish to contribute about themselves. Please include some details about yourself below. Occupation Marital Status Religious Outlook Qualifications Special knowledge Interests Self profile Page 4 of 5

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