Thank you for your interest in joining Auckland City Council's community feedback panel, Listening Post. To become a member you must have an e-mail address and complete this form. We ask for details that will help us understand the range of feedback we receive, correspond with you appropriately, and provide suitable access and meeting facilties should we meet. Your details and feedback will be used for Auckland City Council consultation purposes only and will be held in the strictest confidence. Title Mr Mrs Ms Miss Dr Other (please specify) First name Family name If you are representing an organisation on Listening Post, please tell us its name Are you the person solely or jointly responsible for paying rates to Auckland City Council for a property you own? yes no Street address Suburb City Country Your e-mail address (please check carefully as this is how we will correspond with you) We would like you to provide us with some optional personal information to help us understand the range of responses we receive from the Listening Post membership and ensure that we make your Listening Post participation as easy as possible. Which gender are you? Male Female What year were you born? before 1930 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 To ensure we provide for members' needs at Listening Post consultation events, please indicate any facility (such as wheelchair access or a hearing loop) that needs to be available for you to take part. Which ethnic group(s) do you belong to? New Zealand European Tongan Maori Niuean Samoan Chinese Cook Island Maori Indian Other (please specify) Which language(s) are spoken in your home? English Cook Island Maori Maori Hindi Samoan Korean Cantonese Tongan Mandarin Niuean Other (please specify) Including yourself, how many people usually live in the same house or apartment as you? 1 2 3 4 5 6 7 8 9 10 or more What is your household's (or apartment's) annual income? less than $20,000 $20,000 - $30,000 $30,001 - $40,000 $40,001 - $50,000 $50,001 - $70,000 $70,001 - $100,000 $100,001 - $130,000 $130,001 - $160,000 $160,001 - $200,000 more than $200,000 I'd prefer not to say