Australian Capital Territory
Electoral – Approval of form – Application to be a candidate for a casual vacancy 2003
Approved form AF2003 — 2
made under the
Electoral Act 1992, s 340A (Approved forms)

I hereby approve the attached casual vacancy application form for the purposes of section 192 of the Electoral Act 1992. 

Phillip Green
Electoral Commissioner
14 January 2003

Email:

Application to be a Candidate for a 
Casual Vacancy in the ACT Legislative Assembly

ACT Electoral Commissioner, 48-56 Allara Street, Canberra City	PO Box 272 Civic Square ACT 2608
Phone: 6205 0033       Fax: 6205 0382       Email: elections@act.gov.au        Website: www.elections.act.gov.au

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*Where a candidate’s address is suppressed from the electoral roll, this form should not show that address, but in that case the candidate must notify the Commissioner in writing of a correspondence address for the candidate.

Contact numbers:

Name of contact officer:

The person named as contact officer should be someone who can readily relay information to the candidate.

Office use only

Date received:

	/	/

Time received:

	am/pm

Signature:

Date:

	/	/

Signature of candidate:

Residential address* 
of candidate:

	

Full name of candidate:

Contact details for candidate

Signature of witness:

	

Enrolled address 
of witness:

Witness

Full name of witness:

I am an elector on the Australian Capital Territory electoral roll.  I saw the applicant sign this form.
I am satisfied as to the identity of the applicant and that all the statements in it are true.

To the Electoral Commissioner 
I hereby apply to be a candidate for the casual vacancy in the electorate of [insert electorate name] caused by the resignation of  [insert name of former MLA] MLA.
I state that I consent to be a Member of the Legislative Assembly if elected.
I declare that I am a person eligible to contest this casual vacancy.

Candidate

This application must be completed and lodged with the Commissioner at the above address by noon, [insert closing date].

Elections ACT