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Liberal Membership 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
Residential Address
Town / Suburb
Postcode
Postal Address
Town / Suburb
Postcode
DOB 1
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DOB 2
1
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5
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26
27
28
29
30
31
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
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1935
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1940
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1942
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1945
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1948
1949
1950
1951
1952
1953
1954
1955
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1957
1958
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1961
1962
1963
1964
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1978
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1996
1997
1998
Phone (H)
Phone (W)
Phone (M)
Email Address 1
Email Address 2
I would prefer to receive correspondence via email
No
Yes
Introduced by
Branch to join
- -
Electorate of Bass
Bridport
East Launceston
East Tamar
Elphin/Newstead
George Town
Launceston Business Branch
Launceston Central
Launceston City
Launceston Northern Suburbs
Launceston Womens Group
Launceston Young Liberals
Legerwood/Ringarooma
Norwood
Riverside
Scottsdale
South Launceston
Trevallyn
West Launceston
Electorate of Braddon
Braddon Business Branch
Burnie
Circular Head
Devonport City
Devonport Women's Group
King Island
North West Primary Industry Branch
Ulverstone
Electorate of Denison
Claremont
Denison Business Branch
Glenorchy
Hobart City
Hobart Women's Group
Lower Sandy Bay
New Town/North Hobart
Queenborough
Sandy Bay
West Hobart
Electorate of Franklin
Acton/Cambridge
Bellerive
Central Franklin
Derwent
East Derwent/Rosny
Howrah
Huon
Kingston
Lindisfarne
Southern Young Liberals
Western Franklin
Electorate of Lyons
Break O'Day
Derwent Valley
East Coast
Northern Midlands
Port Sorell
South East Lyons
South Esk
Southern Lyons Women's Group
Southern Western Lyons
West Tamar
Western Lyons
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
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
- -
01
02
03
04
05
06
07
08
09
10
11
12
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13
14
15
16
17
18
19
20
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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