Company / Organisation:

Name:

Email:

Physical Address:

Postal Address:

Phone:

Fax:

Position in Organisation:

Consent to disclosure of your company details on our members section of the website:

Yes     No

Website address:

Number of Staff:

Representative on Council:

Nature of Business:

Are you happy for us to use email as much as possible in communicating with you?

Yes     No

Email addresses of 4 staff who you would like to receive a weekly bulletin:

• 1.
  
• 2.
  
• 3.
  
• 4.
  

Specify products/services/sectors of interest to you with respect to Latin America:

Specific countries of interest to you in Latin America:

Annual Subscription Rates (all GST inclusive):

To be paid by 20 February 2012.
There is a 50% discount for new members for the first year if your application is received after 30 June.

Payment should be made by direct credit to our bank account -
01 0527 0067252 00; or by cheque made out to the Latin America New Zealand Business Council.

Please return this form and a cheque for the appropriate amount, to:
Latin America New Zealand Business Council

PO Box 33094,
Takapuna, Auckland 0740

Membership List Distribution - We value our Members and we do not make their information publically available. Should you wish to have information on those members who have consented to the disclosure of certain information, please check our website www.lanzbc.co.nz.

This application form becomes a Tax Invoice on payment of the subscription fee TAX INVOICE GST NO. 58 662 089

By submitting this form you are agreeing to our Terms and Conditions of membership.