Membership to REXIT.AU Reef State

Become a Bravehart.

Be it knowen that you are a member of the New State movement.

Membership includes

• Participation in Advocacy
• Receive Newsletters and Notices
• Input to the activities of the Management Committee
• Apply to Join the Management Committee

If you’re unable to sign up online, please download and complete the Rexit.au Reef State Campaign Membership Application form. Print Form

(* = required field)

Title Title Mr Ms Mrs Miss Master Madam

First Name *

Last Name *

Business Name

D.O.B Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month Month 01 02 03 04 05 06 07 08 09 10 11 12

Year Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901

Phone

Mobile

Parsonal Email

Work Email

Address

City

State State Qld NSW Vic WA SA Tas ACT NT

Postcode *

Participation Level

Passive: To be kept informed via email updates.

Active: Assist with recruiting members, fund raising, Social media admin, other tasks.

Committed: Serving on committees, assist with recruiting members, fund raising.

Business participation: Would like to display business support on promotional material.

Leave us a message regarding what you beleive could help the REXIT.AU Reef State Campaign.

Terms & Conditions:

* Please click this box to indicate you have read and agree to REXIT Inc. Reef State Terms and Conditions.

Submit