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Liberal Membership Renewal Application
Personal Details
Items in
red
are required fields.
Title / Surname 1
Mr
Mrs
Miss
Ms
Dr
Title / Surname 2
Mr
Mrs
Miss
Ms
Dr
Given Name 1
Given Name 2
Email Address
I would prefer to receive correspondence via email
No
Yes
Subscription Details
Please tick
ONE
of the following options:
1 July to 30 June
Single ($70.00)
Family ($100.00)
Pensioner / Senior - Single ($30.00) *
Pensioner / Senior - Family ($42.00) *
Full-time Student / Young Liberal / Junior Member ($30.00)
Financial Member for Life ($3500.00)
* Pension Card No
Would you like to donate
Yes
No
Donation Amount
Total Amount
Payment Method & Details
Please select
ONE
of the following options:
Cash (delivered in person to office)
Cheque (payable to 'Liberal Party of Australia - TAS Division')
Credit Card - fax or post
Credit Card - online (enter details below)
I agree to have my membership renewal automatically processed and paid for on an annual basis to my credit card each year into the future unless I advise otherwise
No
Yes
Credit Card Type
- -
Visa
Mastercard
Bankcard
AMEX
Credit Card Number
Name on Card
Expiry Date
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02
03
04
05
06
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08
09
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13
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If accepted as a member, I/we agree to adhere to the constitution and
rules of the Liberal Party of Australia, Tasmanian Division.
Authorised by Sam McQuestin, Level 2/24 Murray Street, Hobart TAS 7000 | Updated 14 August 2013 |
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