In order to satisfy the requirements of the Electoral Commission for the purpose of registering "PIRI WIRI TUA MOVEMENT" as a political party under the Electoral Act 1993, I confirm that I am eligible to register as an elector and I authorise the said "PIRI WIRI TUA MOVEMENT" to record my name as a financial member of the "PIRI WIRI TUA MOVEMENT" as at the date shown below and to release my name and address to the Electoral Commission.

Full Name………………………………………………………………………….

Address…………………………………………………………………………....

Signature………………………………………………………………………….

Date………………………………………………………………………….......

Please PRINT this form and fill in the details.

Please include $1.00 membership fee. Please make cheque, money order payable to PIRI WIRI TUA MEMBERSHIP Account and please send a self stamped envelope then post to the following address:-