Tasmanian Liberals

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Liberal Membership Application

Personal Details Items in red are required fields.

Title / Surname 1
Title / Surname 2
Given Name 1
Given Name 2
Residential Address
Town / Suburb
Postcode
Postal Address
Town / Suburb
Postcode

DOB 1
DOB 2
Phone (H)
Phone (W)
Phone (M)
Email Address 1
Email Address 2
I would prefer to receive correspondence via email

Introduced by
Branch to join



	Have you previously been a member of the Liberal Party, any other political party or stood as a candidate for a position in any parliament? No Yes

	If you answered YES to the above question, please provide details:



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
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

Credit Card Type
Credit Card Number
Name on Card
Expiry Date

	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 \| Admin