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Join

1. Personal Details

Surname 1      
  2    
Given Name/s 1      
  2    
Residential Address     Postcode  
Enrolled Address *
* If different from residential address 		  Postcode
Postal Address   Postcode
Date of Birth 1
2
Phone (BH) 1    
2    
Phone (AH) 1      
2    
Mobile      
Email 1      
  2    

2. Party Membership Options (please select ONE)

Do you want to:


PLEASE NOTE: So you will have full rights as a Party Member it is strongly recommended that you join the Conference in the electorate in which you are enrolled.


Federal Electorate Conference
State Electorate Conference

(Optional) Branch Membership. Would you like to join a Branch?

If you have a preferred branch please indicate below.

Branch  

(Optional) Young Liberal Membership. If you are under 31 years of age please indicate if you would also like to join the Young Liberal Movement?

3. Additional Questions (select if applicable)

Do you believe in the values of the Liberal Party - individual dignity, liberty, free enterprise, the family, and personal and community responsibility?

Have you ever previously been a member of the Liberal Party?

Have you ever been a member of any other political party?

Have you ever previously applied for, and been refused Membership of the Liberal Party?

Have you previously been expelled from the Liberal Party?

Have you ever nominated as a candidate in an election for an Electorate or for the Senate/Legislative Council where the Liberal Party has had an endorsed candidate?

I/we apply for Membership of the Liberal Party of Australia (Victorian Division) and agree to be subject to the Party's Constitution and rules of the Party.
Date  
Date

4. Membership Subscriptions*

* Subscription rates for the membership period ending 28 February 2011. Remittance may be by Direct Debit, cheque or credit card.

Membership Type (please select membership category) (One only) Join between 1 Nov 2009 and 30 June 2010 Join between 1 July 2010 and 31 Oct 2010
$96.00 $58.00
$36.00 $23.00
$36.00 $23.00
$132.50 $81.25
$50.00 $32.50
$50.00 $32.50



* PLEASE NOTE: a discount of $10 for joint members and $5 for individuals applies in the first year of payment by Direct Debit.

Credit Card Type
Credit Card Number
Name on Card
Expiry Date
Card Security Code

NOTE: Contributions and gifts to registered political parties, including Membership Subscriptions, are tax deductible (up to $1,500 per annum).