Get Active

Country *

First Name *

Last Name *

Private Email Address

Home Phone Number

Mobile Phone Number

If you live in a block of flats e.g. "George House" OR your house has a name .e.g "Dale Farm Cottage"

Building Name

The street address, the number of your dwelling plus the street that you live on. If you live in a block of flats, put the flat number then the street. Example 1: 10 England Street Exanple 2: Flat 7, England Street

Street Address *

Optional: Please fill in the district where you live.

District

Town / City *

Postal Code *

Preferred Communication Method

Phone
Email
SMS

An activist pack contains : * 200 leaflets, please distribute them. * ReferendumNow petitions - please get your family, friends and workmates to sign them. * 5 Voice of Freedom newspapers. Please sell them and post back a cheque for £3.75 (The price of 5 Voice of Freedom's).

Send me an activists pack

Yes No (clear)

If you are new to the party, you may also want to order an infopack.

Send me an infopack

Yes No (clear)

I can attend meetings

Yes No (clear)

Please state how far you can drive in miles.

I have my own transport and can travel

I can give lifts to other activists

Yes No (clear)

If you have a decent broadband connection at home, that is good enough for voice use (Skype, MSN, Yahoo), please check "Yes".

I have a broadband connection at home

Yes No (clear)

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