Hauraki Māori Trust BoardIwi Registration Form PERSONAL DETAILSRoll Number Title* Mr Mrs Miss Ms Surname/s* First Name/s* Given Name/s Gender* Male Female Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Address* Street Address Address Line 2 City Postcode Postal address* Street Address Address Line 2 City Postcode (If different from above)Home PhoneWork PhoneMobile*Email* TRIBAL DETAILSI am a descendant of (Please tick all applicable boxes below)* Ngāti Hako Patukirikiri Ngāti Paoa Ngāti Tamatera Ngaati Whanaunga Ngāti Rahiri-Tumutumu Ngāti Maru Ngāti Tara Tokanui Ngāti Hei Ngai Tai Ngāti Pukenga ki Waiau Ngāti Porou ki Harataunga ki Mataora None of the above Iwi HiddenFor the purpose of the Hauraki Maori Trust Board Elections, I wish to be registered to vote for* (Name one Iwi above only)For the purpose of the Hauraki Maori Trust Board Elections, I wish to be registered to vote for*Ngāti HakoNgāti HeiNgāti MaruNgāti PāoaPatukirikiriNgāti Porou ki Harataunga ki MataoraNgāti Pukenga ki WaiauNgāti Rahiri-TumutumuNgāi TaiNgāti TamateraNgāti Tara TokanuiNgaati WhanaungaFAMILY DETAILS(Please complete details pertaining to your Hauraki Whakapapa only)ParentsMy Father’s full name is* His Iwi is* Do you know your Father's Date of Birth?* I know my father's date of birth I don't know my father's date of birth My Father's Date of Birth* DD slash MM slash YYYY My Mother’s full name is* Her Iwi is* Her Birth name is* Do you know your Mother's Date of Birth* I know my mother's date of birth I don't know my mother's date of birth My Mother's Date of Birth* DD slash MM slash YYYY GrandparentsMy Father’s Fathers name is His Iwi is My Father’s Mothers name is Her Iwi is Her Birth name is My Mother’s Fathers name is His Iwi is My Mother’s Mothers name is Her Iwi is Her Birth name is My partners name is Is your partner of Hauraki descent? Yes No N/A (If yes, please have your partner complete a separate registration form)ChildrenName Whangai Yes No Gender Male Female Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Name Whangai Yes No Gender Male Female Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Name Whangai Yes No Gender Male Female Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Name Whangai Yes No Gender Male Female Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Name Whangai Yes No Gender Male Female Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address If you have more than 5 children please email us directly at general@hauraki.iwi.nz after submitting this form.Declaration and Statement to comply with the provisions of the Privacy Act 1993*I hereby declare that: 1. I make application to enrol myself, my children under 18 years and any eligible legal dependant/s entrusted to my care, as a beneficiary of the Hauraki Māori Trust Board. 2. I understand that the information I provide will be held by the Hauraki Māori Trust Board at its offices for the purpose of maintaining a register of beneficiaries and any other purpose as it shall determine from time to time to further the objectives of the Board for the benefit of Hauraki iwi. 3. I am a blood descendant from one or more of the Hauraki Iwi with whom I have declared an affiliation in Section 2. 4. All the information contained in this registration form and whakapapa is true and correct. 5. The Hauraki Māori Trust Board, or agent appointed by it, may use this information in order to contact me about Board elections and other matters of importance that may be of interest to me and my Iwi. 6. I authorise the Hauraki Māori Trust Board where appropriate to disclose information about me that may be relevant to this application, the maintenance of the register to which this application relates and any other purpose as it shall determine from time to time to further the objectives of the Board for the benefit of Hauraki iwi provided that any request for access is for a lawful purpose(s) of the Hauraki Māori Trust Board. 7. I have the right at any time to request access to and/or correct the information held by the Hauraki Māori Trust Board. I agree to the privacy act.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, conversion or disposal of settlement quota. The notice will be sent to the address provided on this form Privacy 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, conversion or disposal of settlement quota. The notice will be sent to the address provided on this formSignature*HiddenBoard of Trustee Sign Off (To Print)HiddenVerified by First Last HiddenDateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenSignature Email: general@hauraki.iwi.nz Phone: 07 862 7521 Freephone: 0508 4682 88 41 Belmont Rd Paeroa, 3600 FollowFollow
