THE ELECTORAL REFORM SOCIETY OF WESTERN AUSTRALIA INC.

(WA Branch of the Proportional Representation Society of Australia)

Membership Application Form

Secretary: Mr Norman Cox	Tel.  08 9244 5708
171B Hancock Street
DOUBLEVIEW WA 6018

To the Electoral Reform Society of Western Australia Inc. : 

* I wish to remain on the mailing list.   Yes/No

* I apply for/renew membership of the Electoral Reform Society of Western Australia Inc. from 1st July to 30th June, and enclose $15.00, or $10.00 for pensioners or full time students, as the Annual Subscription.

* I apply for Life Membership ($150)

* I enclose a donation of $.......................  to the Society.

* I understand that membership also makes me a member of the Proportional Representation Society of Australia, of which the Electoral Reform Society of Western Australia Inc. is the Western Australian Branch.

SIGNED: ..........................................................                                    DATE: ..................................  20......

Title (Mr/Dr/Mrs/Miss/Ms etc.)

Given Names

Surname

Address

Postcode

Private Telephone No.

Business Telephone No.

Private Fax No.

Business Fax No.

Mobile Telephone No.

Email Address

(Please make cheques etc. payable "Electoral Reform Society of WA Inc." and return to the Secretary at the above address)

*************