Elections ACT

		Nomination of a Candidate or Candidates 
by a Registered Political Party * 
ACT Legislative Assembly		
	Nomination by Registered Officer		
	To: The Electoral Commissioner		
	I,			
		(Name of Registered Officer)			
	of			
		(Name of Registered Party)			
	hereby nominate the person or persons named on this form as a candidate or candidates for election to the ACT Legislative Assembly for the electorate of: 		
	(Tick one box only)				
	Brindabella:		Ginninderra:		Molonglo:	
					
	(Tick one box only)				
	The registered name:	registered abbreviation:		of the party/group is to be printed on the ballot paper	
					
	Signature of 
Registered Officer:		Date:	/        /		
					
	Contact details for candidates		
	The person named as contact officer should be someone who can readily relay information to the candidates		
	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:			
					
	* “Registered” means registered under the ACT Electoral Act 1992			
	This form is Approved Form AF2004-21 under section 340A of the Electoral Act 1992
02/04	
ACT Electoral Commission		

	Candidate(s) to complete this section		
						
	Candidate 1			Candidate 2		
	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.			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:			Surname:		
						
	Given names in full:			Given names in full:		
						
	Given name(s) to be printed on the ballot paper:			Given name(s) to be printed on the ballot paper:		
						
	Residential address *:			Residential address *:		

	Occupation:			Occupation:		
						
	Signature:			Signature:		

						
	Candidate 3			Candidate 4		
	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.			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:			Surname:		
						
	Given names in full:			Given names in full:		
						
	Given name(s) to be printed on the ballot paper:			Given name(s) to be printed on the ballot paper:		
						
	Residential address *:			Residential address *:		

	Occupation:			Occupation:		
						
	Signature:			Signature:		
						
	* 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.		

	Candidate(s) to complete this section		
						
	Candidate 5			Candidate 6		
	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.			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:			Surname:		
						
	Given names in full:			Given names in full:		
						
	Given name(s) to be printed on the ballot paper:			Given name(s) to be printed on the ballot paper:		
						
	Residential address *:			Residential address *:		

	Occupation:			Occupation:		
						
	Signature:			Signature:		

						
	Candidate 7					
	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:					
						
	Given names in full:					
						
	Given name(s) to be printed on the ballot paper:					
						
	Residential address *:					

	Occupation:					
						
	Signature:					
						
	* 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.