Queensland Greens - Membership

Personal details

New Membership Details (QLD) (Copy)

Is this a new membership or a renewal?

New Membership

Renewal

Email Address *

First Name *

Middle Name

Last Name *

Preferred name

Primary contact phone (preferably mobile) *

Other phone (eg. home)

An alternative phone contact is appreciated, so we can contact you if there are problems with your email or primary phone

Birth Date *

Format = dd/mm/yyyy
Your birth date is required to match you to the electoral roll. You can read our Privacy Policy here.

Further Membership Information (QLD)

Electoral address

Please add your address as on the electoral roll.

Address Line 1 *

Address Line 2

Suburb/Town *

State *

Post Code *

Country *

Postal address

Address Line 1

Address Line 2

Suburb/Town

State

Post Code

OPTIONAL other information

Gender

Woman Man Non-binary Other Do not wish to disclose

Skills to offer / other comments

Payment details

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

Billing Name and Address

Street Address *

City *

Country *

State/Province *

Postal Code *

Summary

Problems?
Contact the Queensland Greens State Office at membersadmin@qld.greens.org.au or you can join or renew by phone (07) 3357 8458.

Information required for legislative compliance (non citizens/residents may still apply but must ring the office to do so (07) 3357 8458)

I am an Australian Citizen or Permanent Resident, and not a prohibited donor as per Queensland legislation