Username E-mail Password At least 7 characters please! Confirm Password Please note: If more than one person joining uses the same email address, please put “000” and “001” etc before your usual email address. A unique email address is required. If you do not have an email address, please show your email as “firstname.lastname@example.org”. Surname Given Names (in full) Residential Address (as on electoral role) City State/Territory ACT NSW NT QLD SA TAS VIC WA Postcode Gender Male Female Date Of Birth (enter as YYYY-MM-DD) Primary Contact Number Secondary Contact Number I am a health practitioner Yes No My association memberships are: HAP_Member* I wish to become a member of the “Health Australia Party” and agree to abide by its constitution. Election_Eligibility* I am eligible to enrol for Australian elections. AEC_Consent* I consent for this form being forwarded to the Electoral Commission as proof of my support for the party’s application for registration. Declaration* I declare that all the information I have supplied on this form is true. You are eligible to enroll if you are an Australian citizen, or eligible British subject, and aged 18 years or over, and have lived at your address for at least one month. When testing the party's membership list, the Electoral Commission contacts members to confirm the membership is valid. Membership lists are retained by the Electoral Commission on a confidential database. I would also like to help in the following Committees Health Research Committee Fundraising Committee Media promotion Committee Policy Committee General Assistance Letter-boxing leaflets Volunteering during office hours Displaying flyers Helping with Stalls Helping with Events/Talks etc General Assistance cont. Helping on Election day Helping with phone calls Using Social Media (Facebook/Twitter) Getting Members Language translation Video Production Legal Other Click on the box below to register as a member of HAP. For new members, please proceed to the payment menu to complete your membership application. The annual membership fee is $25.00.