Elections ACT

		Nomination of a Non-Party Candidate
ACT Legislative Assembly		
	Nomination by Twenty Electors		
	To: The Electoral Commissioner		
	We, electors listed on the following pages and entitled to vote at the election of members of the ACT Legislative Assembly for the following electorate, hereby nominate the person named on this form as a candidate for election for the electorate of: 		
	(Tick one box only)				
	Brindabella:	Ginninderra:	Molonglo:				

	Candidate		

For ungrouped candidates only

The word ‘Independent’ is to be printed 
on the ballot paper next to my name:
	Yes:	No:

	I, THE CANDIDATE NAMED BELOW, STATE THAT:
•	I am an Australian citizen
•	I am at least 18 years of age
•	I am an elector or qualified to be an elector
AND I DECLARE THAT:
•	I am eligible to be nominated for election
•	I consent to this nomination for election and to be a Member of the Legislative Assembly if elected. 					
	Surname:			Residential address *:		
						
	Given names in full:					
						
	Given name(s) to be printed on the ballot paper:			Occupation:		
						
	Signature:	Date:					
	/      /       					
	* Note all details on this form will be publicly available.  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 details for candidate		
	The person named as contact officer should be someone who can readily relay information to the candidate		
	Name of Contact Officer:			
					
	Phone (H):		Phone (W):		Phone (Mob):			
					
	Fax:		Email:			
	Note all details on this form will be publicly available.  If the contact officer does not want to make any of the above details publicly available, please advise the Commissioner in writing of these details on a separate sheet.	
	Office use only		
					
	Date received:	/        /	Time:	am/pm	Deposit received?    Yes	No		
					
	Received by:		Signed:				
	02/04	ACT Electoral Commission		
					
This form is Approved Form AF2004-22 under section 340A of the Electoral Act 1992

	Nominator 1			Nominator 2		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator 3			Nominator 4		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator 5			Nominator 6		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator 7			Nominator 8		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		

	Nominator 9			Nominator 10		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator 11			Nominator 12		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator 13			Nominator 14		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator 15			Nominator 16		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		

	Nominator 17			Nominator 18		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator 19			Nominator 20		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator (extra)			Nominator (extra)		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /       		
					
	Nominator (extra)			Nominator (extra)		
	Surname:			Surname:		
						
	Given names:			Given names:		
						
	Residential address for which enrolled:			Residential address for which enrolled:		

	Date of Birth:			Date of Birth:		
	/        /			/        /		
	Signature:	Date:			Signature:	Date:		
	/      /       			/      /