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THE ELECTORAL REFORM SOCIETY
OF WESTERN AUSTRALIA INC. (WA Branch of the Proportional
Representation Society of Australia) |
Membership Application
Form
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Secretary:
Mr Norman Cox |
Tel. 08 9244 5708 |
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171B
Hancock Street |
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DOUBLEVIEW
WA 6018 |
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To the Electoral Reform Society of Western Australia Inc: * I wish to remain
on the mailing list. Yes/No * I apply for/renew
membership of the Electoral Reform Society of Western Australia Inc. from 1st
July to 30th June, and enclose $15.00, or $10.00 for pensioners or full time
students, as the Annual Subscription. * I apply for Life
Membership ($150) * I enclose a
donation of $....................... to the Society. * I understand
that membership also makes me a member of the Proportional Representation
Society of Australia, of which the Electoral Reform Society of
Western Australia Inc. is the Western Australian Branch. SIGNED: ..........................................................
DATE: .................................. 20...... |
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Title
(Mr/Dr/Mrs/Miss/Ms etc.) |
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Given
Names |
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Surname |
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Address |
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Postcode |
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Private Telephone
No. |
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Business
Telephone No. |
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Private
Fax No. |
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Business
Fax No. |
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Mobile
Telephone No. |
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Email
Address |
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(Please make cheques etc. payable
"Electoral Reform Society of WA Inc." and return to the Secretary at the
above address)
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