Sa+national+membership+and+payment+form

APPLICATION FOR MEMBERSHIP Post this form with payment to Socialist Alliance, PO Box A2323, Sydney South NSW 1235 APPLICANT’S DETAILS (as per electoral roll)

Surname……………………………………………………………………………….

Given Names………………………………………………………………………… RESIDENTIAL ADDRESS (please print, as per electoral roll) Number and Street……………………………………………………………………………………………… Suburb or Town…………………………………………..State…………………………...Postcode……….. Phone (h)……………………………(w)…………………………..(Mobile)……………..……..…….………………. Fax………………………………Email Address………………………………………………………………………... POSTAL ADDRESS (if different from Residential Address) Number and Street………………………………………………………………………………………………………. Suburb or Town…………………………….…………………State….…………………………..Postcode………..

ELECTORAL REGISTRATION CHOICE (Tick the appropriate box)

… Please do not use this application to help the Socialist Alliance achieve electoral registration. Signed__________________________________Date_________/____________________/______ (continue over page)

…

I am willing to have this application used to help the Socialist Alliance achieve electoral registration. (complete details below)

DECLARATION I wish to become a member of the Socialist Alliance. I am eligible to enroll for federal elections (i.e., I am 17 years of age or older, I am an Australian citizen (or a British citizen who was on the Australian electoral roll on 25 January 1984) and I have lived at the above address for at least a month. I consent to a copy of this side of this form being forwarded to the Australian Electoral Commission in support of the Socialist Alliance’s application for registration as a political party. I also consent to the information on this form being used to support the Socialist Alliance’s applications for electoral registration at the State and Territory level. I declare that the information I have given on this form is true and complete. I declare that I have not been convicted of a disqualifying electoral offence in the last 10 years

DATE OF BIRTH

……/……/…………

Signed__________________________________Date_________/____________________/______ NOTE: A copy of this form will be forwarded to the Australian Electoral Commission to confirm that the Socialist Alliance meets the registration requirements. The AEC may contact you to confirm that you are a party member and that you have signed this form. The AEC may enter the details on this form into a data base for cross-checking purposes, and will return the copy of the form to the Socialist Alliance. This information will be treated as confidential by the AEC.

(continue over page)

PARTY USE ONLY This is the annexure marked …………referred to on the statutory declaration (annexure number)

of………………………………………………………sworn the ……………… ………………….day of……………………………………………… (name of person making the declaration)

(month and year)

.….……………………………………………………….. (signature of the person making the declaration)

BEFORE ME..……………………………………………………………… (signature of the person before whom the declaration is made)

MEMBERSHIP SURVEY

… Please contact me about Socialist Alliance events and meetings … Union membership [please name union] … Community Group [please name] ………………………………………………………..

………………………………………………………..

… Campus/high school [please name]

… Other political/campaign organisation

………………………………………………………..

[please name] ……………………………………..

… I am willing to volunteer time to help the work of the Socialist Alliance I would like to help the work of the Socialist Alliance in these areas … IT … Layout and visual arts … Event organisation … Media liaison … Finance and fund raising … Socialist Alliance information stalls … Film, video showings … Bookkeeping … Policy development (please specify areas of interest below) … Other (please specify)…………………………………………….. ………………………………………………………..

I am keen to be actively involved in these Socialist Alliance campaigns … Socialist Alliance election campaigns … Medicare … The antiwar movement … Refugees … Against racism and for Indigenous rights … Local community issues … Women’s rights … Trade union issues … Public education … International solidarity campaigns … Environment … Other (please specify)…………………………………………….

… I have the following skills that may be useful to the Socialist Alliance in its work…………… ……………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………….

Socialist Alliance annual dues z Solidarity $100 z High-waged $60 z Waged $30 z Tertiary student, unemployed, low-waged $15 z High school student $5

Green Left Weekly subscription rates z Introductory (7 issues) $10 z 3 months (11 issues) $22 z 6 months (22 issues) $44 z1 year (44 issues) $83 z 2 years (88 issues) $154

Make a regular contribution to the Socialist Alliance! I want to make a regular contribution to the Socialist Alliance. Please contact me to organise payment arrangements AMOUNT……………

BRANCH USE ONLY ___________________________ Branch … Membership card issued/sent Electorates __________________________(Federal) ____________________________(State)

… Receipt issued/sent … Details entered in data base … Electoral roll checked

I want to join the Socialist Alliance. Here are my annual dues Solidarity — $100

High-waged — $60

Welfare/low-waged/tertiary student — $15

Waged — $30 School student — $5

I would like to make a regular monthly pledge of $______

I want to make a donation to Socialist Alliance $1000 Other

$750

$500

$250

$100

$50

$__________

I want to subscribe to Green Left Weekly Introductory (7 issues) — $10

Three months (11 issues) — $22

Six months (22 issues) — $44

One year (44 issues) — $83

Two years (88 issues) — $154

Here is my total payment of $__________ I am paying by

Cash

Mastercard

Cheque etc

Credit card

Visa

Card number Expiry

/

Alternatively, you can pay by making an electronic funds transfer to our bank account (Socialist Alliance National Account, BSB: 062 018, #1010 9498) and emailing us your details at national_office @socialistalliance.org.

Here are my contact details Name

Date

Address Suburb Phone

Postcode Mobile

Email Return to Socialist Alliance, PO Box A2323, Sydney South, NSW 1235. We can also be contacted on 02 9690 2508 or by email at national_office @socialist-alliance.org.