Approved form AF2002-98

made under the
Health Professions Boards (Elections) Act 1980

Health Professions Boards (Elections) Act 1980—Form 1
(see s 8)

Health Professions Boards (Elections) Act 1980
Nomination for Election of Member
OF THE	(a)	Chiropractors and Osteopaths Board
	(a)	Dental Board
	(a)	Medical Board
	(a)	Nurses Board
	(a)	Optometrists Board
	(a)	Pharmacy Board
	(a)	Physiotherapists Board
	(a)	Veterinary Surgeons Board
To the returning officer
We, the undersigned, being persons who were, on (date fixed for purpose of section 5 (1) (a)) registered practitioners for the purposes of the forthcoming election, hereby nominate the following person as a candidate for election as a member of the board.
Full name of candidate:
Registered address of candidate:
Full name and registered address
 of nominator	Signature of 
nominator	Date of
signature	

1.

2.

Consent and declaration of person nominated
I,                                       of (registered address)                                        , the person nominated for election above, consent to act, if elected, and declare that I am eligible under the Health Professions Boards (Elections) Act 1980 to be nominated as a candidate at the forthcoming election.
Dated:
Signature of candidate:
Signature of witness:
Note	The Health Professions Boards (Elections) Act 1980, sections 35 and 36 read as follows:
35	Untrue statements
A person shall not knowingly make a false statement in a declaration or statement made for this Act.
Maximum penalty:  50 penalty units.
36	Duty of witness
A person shall not witness the signature of another person to a declaration made for this Act unless the person acting as witness—
	(a)	is at least 18 years old; and
	(b)	has satisfied himself or herself about the identity of the person making the declaration; and
	(c)	has seen the person sign the declaration in the person’s own handwriting; and
	(d)	knows, or has satisfied himself or herself by inquiry from the person making the declaration or otherwise, that the statements contained in the declaration are true.
Maximum penalty:  10 penalty units.

Endnotes
1	This form was originally in the Health Professions Boards (Elections) Act 1980 (the authorising Act), schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the authorising Act and became a form approved under the authorising Act, section 39 (see amdt 1.2057, amdt 1.2058).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002