| First Name |
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| Surname |
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| Gender |
(please specify your gender)
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| Your title |
eg: Prof, Dr, Mr, Mrs, Ms, Other |
| Your e-mail address |
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| When we e-mail you, how would you like us to address you? |
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| Which one of the following best describes your age group? |
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| Which ethnic group or groups do you belong to? |
Please select all that apply
Other (Please specify):
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| To which Iwi do you belong? |
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| Which best describes your household's annual income before tax? |
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| Which best describes your annual personal income before tax? |
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| Are you in paid employment? |
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| Which of the following best describes your occupation? |
Other (Please specify)
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| What is the main activity of the business or employer you work for? |
Other (Please specify)
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| Which of the following best describes your highest educational qualification? |
Other (Please specify)
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| Which of the following best describes your household? |
Other (Please specify)
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| Which of the following best describes your involvement in making decisions on behalf of your household? (optional) |
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| During the last 12 months, have you personally participated in any decision on behalf of your employer or company to purchase goods or services to the value of...? (optional) |
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Your telephone numbers (optional)
We would like at least one telephone number to verify your registration and to contact you if you win prizes! All information is
confidential.
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| Local Government Area |
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| Suburb (for Auckland Region Only) |
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| Post Code (optional) |
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| Parliamentary Electorate |
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| Who did you vote for in the 2008 general election? (Party vote) |
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| Who did you vote for in the 2011 general election? (Party vote) |
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Enter a password to allow you to log in and update your details
(or keep this password that has been randomly generated)
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What is the sum of the following two numbers:
This ensures a person, not an automated program, is registering.
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3 + 9 =
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