STATEMENT OF THE PARTY MEMBERSHIP
Party Name
Micro Business Party (MBP)
Surname *
Your answer
Given Names *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Residential Address *
Your answer
City / Suburb *
Your answer
State *
Your answer
Postcode *
Your answer
Telephone *
Your answer
Email *
Your answer
Declaration
1. I wish to CONFIRM I am a member of the above party

2. I consent to this town being forwarded to the Western Australian Electoral Commission in support of the parts application for registration. Strike out if not applicable_ See note below.)

3. I declare that all the information I have given on this form is true and complete.

*
Required
Date
MM
/
DD
/
YYYY
Please note regarding point 2 above: A copy of this form may be forwarded to the Western Australian Electoral Commission to confirm that the party meets the party registration requirements_ The WAEC conducts random surveys to verify membership and it is possible that you may be asked to confirm that you signed this form. Information an the form will be treated by the in strictest confidence_ It will only be used to verify the party's entitlement to registration and for no other purpose.
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