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Sex Male Female Other Full Name LEAVE THIS BLANK Choose Your Payment Method Pay with PayPal or credit card Pay by Electronic Funds Transfer More Information type of cycling Club - racing, social, triathleteCommuter/utility cyclingParent of child cyclistProfessional cyclistRecreation, touringnon cyclist - industryNon-cyclist * type of bike Road bike (incl racing)Utility/commuterMountain bike & trialsHybridBMXTriathlonElectricCargoTouringSingle speedFixieFoldingBikeshareDon't own a bike * Motivation education - for kidseducation - for motoristsenvironment - city planning, infrastructureenvironment - global warming, pollutionhealth, fitness, weighthealth - less stress, more joyaccess to national parksbetter & more offroad bike pathstransport - integrated with public transportbetter & more onroad bike pathspublic bike storagesafer roadsother Other Declarations Please tick all boxes to become a member of Australian Cyclists Party I hereby apply to become a member of The Australian Cyclists Party * I declare that I am not a member of another political party * I declare that I am enrolled on the electoral roll at my address as shown above * I consent to my membership details being sent to the AEC or the relevant State Commission and to being contacted by the commission about my membership of this political party if so required * For NSW residents only: I have downloaded completed and signed the NSW Declaration of Party Membership form and have emailed it to: Angus@icycleivote.com Things I can do to help: Help at polling booths and distributing leaflets Attend meetings Become a candidate - stand for election and effect change Fundraise - crowd funding and more Billing Address First Name Last Name Address 1 Address 2 City State Postal Code Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands US Armed Forces Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Phone Processing...