Prefix: Dr. Miss Mr. Mrs. Ms. Mx. None First Name: Middle Name: Last Name: Gender Female Male Other Address: Address Line 2 Suburb: City: Region Northland Auckland Waikato Tairawhiti (Gisborne) Napier/Hastings Eastern Bay of Plenty Tauranga/Western BoP Taranaki Wanganui Palmerston North Hutt Valley Wellington Nelson Marlborough Otago Christchurch & Districts Ashburton Aoraki/Timaru Southland Postcode Home Phone: Mobile: Other Phone: Email Address: Email Address - other: Membership: Type of Impairment Access Requirement Ethnicity Preferred Contact Method Preferred Format for Publications Not Applicable Audio Braille Easy Read Large Print NZSL Electronic Topics of Interest Computer Access Yes at home Yes at work / library No Internet Access Yes at home Yes at work / library No Do you have a cell phone Yes No How do you prefer to receive information from DPA? Are you interested in providing input to the work DPA does? Yes No If yes, how do you wish to be contacted for information? Code of Conduct Acceptance