APPLICANT’S DETAILS
(as per electoral roll)
Surname……………………………………………………………………………….Given Names…………………………………………………………………………
RESIDENTIAL ADDRESS
(please print, as per electoral roll)
Number and Street
………………………………………………………………………………………………
Suburb or Town
…………………………………………..
State
…………………………...
Postcode
………..
Phone (h)……………………………(w)…………………………..(Mobile)……………..……..…….……………….Fax………………………………Email Address………………………………………………………………………...
POSTAL ADDRESS
(if different from Residential Address)
Number and Street……………………………………………………………………………………………………….Suburb or Town…………………………….…………………State….…………………………..Postcode………..
ELECTORAL REGISTRATION CHOICE
(Tick the appropriate box)
Please do not use this application to help the Socialist Alliance achieve electoral registration.
Signed__________________________________Date_________/____________________/______
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I am willing to have this application used to help the Socialist Alliance achieve electoral registration.
(complete details below)
DECLARATION
I wish to become a member of the Socialist Alliance. I am eligible to enroll for federal elections (i.e., I am 17 years of age or older, Iam an Australian citizen (or a British citizen who was on the Australian electoral roll on 25 January 1984) and I have lived at the aboveaddress for at least a month.I consent to a copy of this side of this form being forwarded to the Australian Electoral Commission in support of the SocialistAlliance’s application for registration as a political party. I also consent to the information on this form being used to support theSocialist Alliance’s applications for electoral registration at the State and Territory level.I declare that the information I have given on this form is true and complete.I declare that I have not been convicted of a disqualifying electoral offence in the last 10 years
DATE OF BIRTH
/
/
Signed__________________________________Date_________/____________________/______
NOTE: A copy of this form will be forwarded to the Australian Electoral Commission to confirm that the Socialist Alliance 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 data base for cross-checking purposes, and will return the copy of the form to the Socialist Alliance. This information will be treated as confidential by the AEC.
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PARTY USE ONLY
This is the annexure marked …………referred to on the statutory declaration
(
annexure number)
of
………………………………………………………
sworn the
……………… ………………….
day of
………………………………………………
(
name of person making the declaration
)
(month and year)
.….………………………………………………………..
(signature of the person making the declaration)
BEFORE ME
..………………………………………………………………
(signature of the person before whom the declaration is made)
APPLICATION FOR MEMBERSHIP
Post this form with payment to
Socialist Alliance, PO Box A2323, Sydney South NSW 1235
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