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FIRST NAME *
LAST NAME *
USERNAME *
PASSWORD *
EMAIL *
DAYTIME PHONE *
(for contacting you
for prizes)
(area)
(local)
MOBILE PHONE
--
021
022
027
029
(prefix)
(number)
DATE OF BIRTH *
1
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5
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7
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9
10
11
12
13
14
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31
1
2
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5
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STREET ADDRESS *
SUBURB *
NEAREST NZ CENTRE *
-- select center --
Auckland
Bay of Islands
Blenheim
Christchurch
Dunedin
Gisborne
Greymouth
Hamilton
Hastings
Havelock North
Invercargill
Kaitaia
Mt Maunganui
Napier
Nelson
New Plymouth
Ohakune
Outside NZ
Palmerston North
Picton
Queenstown Lakes
Rotorua
Taupo
Tauranga
Timaru
Wanganui
Warkworth
Wellington
Whakatane
Whangarei
GENDER *
-- select gender --
Female
Male
OCCUPATION *
-- select occupation --
Administration
Education and Training
Financial/Operations
Hospitality
Marketing/Sales
Medical
Retail
Social Services
Student
Technology
Corporate/Executive
Other
WORK LOCATION
MAIN REASON FOR
VISITING US
(use the ctrl key to select more than one option)
--select interests--
After work drinks
Bands
Catch up with friends
Food special events
Guest DJs
Other
Quiz Nights
Rugby
Special events
PREFFERED EMAIL FORMAT
-- select format --
HTML (images)
Text
YES, I WISH TO RECEIVE EMAIL COMMUNICATION
YES, I WISH TO RECEIVE PHONE TEXT MESSAGE COMMUNICATION
YOU WERE REFERRED BY (EMAIL)
Mon-Fri = Thirsty Madness from $5 Selected Tap Beer & House Wine | Monday & Tuesday = $25 Movie Meal Deal | Wednesday = Quiz Night from 7.30pm | Thursday = Loyalty Draw 6 - 8pm - Live Music from 8pm | Fri = 2 4 1 BUBBLES 7-9pm
