Organisation Address *

Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Organisation Contact *

First Name

Last Name

Membership Fees *

Please select from the options below.

Commercial Entity - One-off joining fee of $5,000 plus annual subscription of $5,000

Not-for-Profit Organisation - Annual subscription of $500 (no one-off joining fee required)

I agree that: *

My organisation will become a member of the New Zealand Hydrogen Council following acceptance of this application and payment of the appropriate membership fee.

My organisation agrees to comply with the New Zealand Hydrogen Council Constitution and other regulations agreed by the Board and published on the Council’s official website.

This membership is non-transferrable without prior written approval from the Board.

My organisation may terminate membership to the New Zealand Hydrogen Council at any time upon written notice to the Board, but I understand that my organisation will not receive a refund of the joining fee, or annual subscription dues already paid for the year of termination.

I authorise: *

The New Zealand Hydrogen Council to acknowledge my organisation's membership through the use of its name and logo in publicity materials and on the Council's website.

The New Zealand Hydrogen Council to issue a tax invoice upon acceptance of the application. All fees exclude GST. The first invoice for the annual subscription is prorated from the joining date to financial year end.

Declaration *

I declare that the information provided on this form is complete, accurate and up to date, and I am not aware of any circumstances which may affect this application other than those I have disclosed on this application form.

Signed *

First Name

Last Name

Date *

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DD

YYYY