Approved form AF2002-100

made under the
Health Professions Boards (Elections) Act 1980

Health Professions Boards (Elections) Act 1980—Form 3
(see s 16 (3))

Health Professions Boards (Elections) Act 1980
Declaration by voter
I,                                 of                                                 (registered address), declare that I am eligible under the Health Professions Boards (Elections) Act 1980 to vote at the election of a member (or of members) 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
, the poll for which election closes on
    , and that I have not previously voted at the election.
Signature of voter
Signed before me		on		
Signature of witness:
Address 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