Citizens' Panel

The information supplied by you in this form is subject to the Privacy Act 1993, and the Local Government Official Information and Meetings Act 1987 (please see below).

Full Name *

First Name

Last Name

Postal Address *

Address Line 1

Address Line 2

City

Postcode

Daytime Phone Number *

Phone Number

Email *

Email

Suburb or nearest urban area or town *

Gender *

Male
Female

Year of birth *

Ethnic Group

New Zealander
Maori
European
Pacific Islander
Asian
Other, please state:

Occupation *

Acknowledgement
I agree to be a part of the NPDC Citizens’ Panel. I understand that:
-I may be asked to participate in a maximum of four consultations within any twelve month period, and that I may refuse to participate at any time;
-I may withdraw from the citizens’ panel at any time by advising the council accordingly.

Privacy Act 1993
I consent to my personal information being held in a council database, and understand that this information will be used only for the purposes of my participation in the citizens’ panel.
I understand that I have rights of access to my personal information and to request its correction where necessary.

I agree that all information provided by me as part of the NPDC Citizens’ Panel is given on the basis that the council protects my privacy to the extent provided by the Local Government Official Information and Meetings Act 1987. *

Yes
No