I wish to become involved in THE GREENS (W.A.)

NAME: ...........................................................................

ADDRESS: ........................................................................

.......................................................... Post Code: ...........

PHONE CONTACTS:(W) ............................. (H) ............................

FAX CONTACT: ..................... E-mail: ......................................

I would like to be involved in: (please circle)  LOCAL GROUP   POLICY   ELECTIONS
FUNDRAISING   NEWSLETTER   ADMIN   OTHER (please specify)

.................................................................................
I would like to contribute the following skills/resources:

.................................................................................

.................................................................................
I would like to become: (please circle)
MEMBER      SUPPORTER      ASSOCIATE(member of another Party)
NEWSLETTER SUBSCRIBER ONLY

Membership Fee: (self assessed, based on your income level)
HIGH $50-      MEDIUM $30-      LOW $15-      NEWSLETTER ONLY $20-

I wish to donate $..................to the Greens(WA) being for:-
[ ]   The Campaign for a Green Republic
[ ]   Federal Election Campaign Fund
[ ]   General Donation
[ ]   other ....................................................................
(donations between $2- and $100- are tax deductible)

I declare that: (please circle)
I AM NOT a member of another political party
		OR
I AM a member of the ...................................................   party
I agree to abide by the constitution

Signature: ............................................ Date: ...................

I enclose: [ ] Cheque, [ ] Bank Draft,
PLEASE MAKE FUNDS PAYABLE TO: THE GREENS(W.A.)
Or Please debit my [ ] Visa, [ ] Mastercard, [ ] Bankcard

Full Name of Cardholder: ........................................................

Card Number: ............................................. Exp: ....... / .......

Signature: .............................................. Date: .................

Authorised by The Secretary, The Greens (W.A.)

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