Membership Application Please complete ONE form per person

MANDATE OF INSTRUCTION IN SUPPORT OF THE
HORIMATUA EVANS CLAIM (WAI No. 98, 526 & 971)

, DESCENDENT OF UETAHA & RONGOMAITAPUI
Eponymous* Tipuna Ruawaipu

Surname
Your family name
First name/s
Date of birth
Gender	Male Female
Address
Phone no.
Fax no.
E-mail
Occupation

I, a descendent of Uetaha, and Rongomaitapui hereby support the HORIMATUA (George) EVANS Claim (WAI No. 98, 526 & 971) that was lodged with the Waitangi Tribunal on the 7th February 2002 and give the nominated persons of the committee my consent to act in my best interests for the purposes of the claim and any settlement negotiations with the Crown. I Agree Disagree
CHILDREN - Please list below
Name	DOB Male Female
Name	DOB Male Female
Name	DOB Male Female
Name	DOB Male Female
Name	DOB Male Female

Privacy Act 1993. The information provided in this application, will remain confidential in accordance with the principles and statutory provisions in the Privacy Act 1993.

*giving one's name to a tribe, place, etc. – Ancestral Tribal Tipuna