Australia's Voice Membership Form

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Please complete this form to become a member of Australia's Voice.

Email *

Are you a member of another Political Party? *

Yes, please resign from that Political Party before continuing with our application

No, please continue

What is your name as it appears on the Electoral Role? *

What is your street address (as it appears on the Electoral Role)? *

Suburb? *

State *

Victoria

Other:

Postcode? *

Is your postal address different from your residential address? *

Yes

What is your postal address?

Contact phone number? *

What is your date of birth? *

YYYY

Membership is valued at $100, however if you are a concession holder or are having financial difficulties a reduced rate of $20 applies. You do not have to provide evidence, and you can pay what you can afford. How much can you pay for your membership? *

$100

$75

$50

$20

Other:

A copy of your responses will be emailed to the address you provided.

Submit

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