Special Assistance Funding Name * First Name Last Name Email * Phone (###) ### #### Date of Birth Current Club Application Declaration Amount applying for Declaration IF THE NZPFA AGREES TO PROVIDE ME ANY SUPPORT FROM THE SPECIAL ASSISTANCE FUND, I AGREE (where applicable): 1. To allow any and all outstanding NZPFA membership subscription fees to be deducted from the amount the NZPFA elects to forward you; and 2. I declare that I have read and understood the NZPFA Special Assistance Funding criteria (to be provided) and further declare that all the information I have provided is true and correct. I understand and accept that the information I have provided on this form will be made known to the NZPFA Working Group for the purposes of assessing my claim but will not otherwise be disclosed by the NZPFA without my written consent. I agree Signature Date MM DD YYYY Thank you. A member of the NZPFA staff will be in touch.