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I, of elect to donate an amount of $ to the Western Australia Division of Pauline Hanson's One Nation Party (State of WA) to be used for a State electoral purpose. I acknowledge that the gift has been accepted as a political donation.

I hereby agree to abide by the contribution rules for One Nation Western Australia. I further certify that I am not a foreign donor under the Commonwealth Electoral Act 1918.

ABN 14 643 634 933

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