Residential Address

City/suburb

State

Postcode

Telephone(W) (   )                     Telephone (H) (   )                      Fax (   )

Declaration

I wish to become a member of the above party.

I am eligible to enrol for Federal elections.

(You are eligible to enrol for Federal elections if:- you are 17 years of age or older; and you are an Australian Citizen; and you have lived at your present address for at least the last month.) (British subjects who are not Australian citizens are eligible to enrol for Federal elections if they were on a Commonwealth of Australia electoral roll on 25 January, 1984.)

* I consent to this form being forwarded to the Australian Electoral Commission in support of the party's application for registration. (Strike out if not applicable.)

I declare that all the information I have given on this form is true and complete.

Signature                                                   Date    /    /

* Please note: This form may be forwarded to the Australian Electoral Commission to confirm that the party meets the party registration requirements. The AEC conducts random surveys to verify membership and it is possible that they may contact you asking you to confirm that you signed this form. The form will be treatedby the AEC in strictest confidence. It will only be used to verify the party's entitlement to registration and for no other purpose. The form will then be returned to the party. No copy or information contained in the form will be kept by the AEC.