Secret Ballot Campaign
– Application for Party Membership

Applicant details (please print clearly)

Surname                                                 Other names

Residential address

             Postcode

Phone no. (home)                                 Phone no. (work)                              Phone no. (Fax)                                     Mobile No.

Email:                                                                                                                       Birth Date (dd/mm/yyyy)

Declaration

I wish to become a member of the above political party.

I am eligible to enrol for Federal elections i.e.  I am 17 years of age or older, I am an Australian citizen (or a British citizen who was on the Australian Electoral roll on 25 January 1984) and I have lived at the above address for at least one month.

I consent to this form being forwarded to the Electoral Commission in support of the party’s application for registration as a political party (delete if not applicable)

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

Signature              Date

This form may be forwarded to the Australian Electoral Commission to confirm that the party meets the registration requirements. The AEC may contact you to confirm that you are a party member and that you have signed this form. The AEC may enter the details on this form into a database for cross-checking purposes, and will return the form to the party. The information will be treated as confidential by the AEC.

Party Use only

This is the annexure marked              (Annexure number)

referred to in the statutory declaration sworn by me                                                                                     (name of party secretary)

 on the                                                                    day of                                                     20

Signature (person making the declaration)                                                                           Signature (person witnessing declaration)