Membership Application
Total Page：16
File Type：pdf, Size：1020Kb
Inc. No. 9892436 PO Box Q1715 Queen Victoria Building NSW 1230 Membership http://pirateparty.org.au/ [email protected] Application Details of Applicant Please print Given name(s) clearly. Surname Street Use a black or Residential Address blue pen. Suburb State Postcode Street Postal Address (Leave blank if same) Suburb State Postcode Telephone (Home) Telephone (Work) Telephone (Mobile) Fax Email address Date of birth / / Gender (optional) DD MM YYYY Declaration and Membership Requirements I wish to become a member of the Pirate Party Australia. I have read and understand Note: This form will be forwarded to the AEC to confirm that the party meets the the Pirate Party Australia Constitution and agree with its platform and principles, and registration requirements. The AEC may will to the best of my ability work to uphold and promote them. contact you to confirm that you are a party member and that you have signed this form. The AEC may enter details of I am enrolled for Federal elections, i.e. I am 17 years of age or older. I am an this form in to a database for cross- Australian citizen (or a British citizen who was on the Australian Electoral roll on 25 checking purposes, and will return the of January 1984) and I have lived at the above address for at least one month. I form to the party. consent to this form being forwarded to the Australian Electoral Commission (AEC) This information will be treated as in support of the party’s application for registration as a political party. confidential by the AEC. I declare the information provided on this form to be true and complete. Date Signature Have you been a member of another political party in the last 12 months? Yes No If yes, please write the name of the party here: Payment and Submission Founding members pay a $20.00 fee, to help with the costs of incorporation, registration and the ongoing costs of setting up and running a political party. This fee is offset against the ongoing party yearly membership fees of $20.00. If you’d like to donate more, it is most welcome. For payments over $50.00 we’ll get some swag out to you as soon as we get that finalised. Of course, your greatest donation will be your time. WAIVED Payment methods Founding Member $20.00 Send your application to us by: Bank deposit (preferred): Email: [email protected] Name: Pirate Party Australia Incorporated And I’d like to donate $ Account number: 138 718 051 Fax: (02) 8088 1346 Total BSB: 633-000 (Bendigo Bank) Post: Pirate Party Australia Please use your phone number as reference PO Box Q1765 Queen Victoria building Cheques: NSW 1230 Payable to: Pirate Party Australia Other methods: Follow payment instructions at http://www.pirateparty.org.au/payment This is the annexure marked _____________ referred to in the statutory declaration sworn by me ________________, the Party Secretary, on the ____/____/________ Party Secretary Signature Witness Office use only.