$25 Annual Membership

I apply for Associate Membership to the Informed Medical Options Party and declare that I am on the Commonwealth Electoral Roll and I am committed to the aims of the Party. (Please ensure after submitting the form below you select your payment option).

Address (as on the Commonwealth Electoral Roll) *

Date of Birth *

Phone Number *

Email address *

Submit Form

NOTE: Please ensure you have clicked on "SUBMIT FORM" and it displays

"THANKS, YOUR SUBSCRIPTION HAS BEEN SENT". If not displayed, please resend.

Thank you for membership. To make your $25 payment, please choose from one of the following payment options:

BANK DEPOSIT:

Account Name: Involuntary Medication Objectors Party
BSB: 062 560 A/C: 1044 8211

CREDIT CARD: