Elections ACT

Scrutineer Appointment Form	
	
Please use BLOCK LETTERS	
To the officer in charge:	
at		
	(Polling Place/Scrutiny Centre)	
I hereby appoint		
	(Surname or family name)	(given names)	
of		
	(Residential address)	
to act as my scrutineer at your Polling Place/Scrutiny Centre for the ACT Legislative Assembly election/referendum for which I am a candidate.	
Signature of candidate 			/          /	
	
Name of candidate		
	(as it appears on the ballot papers)	
Name of Registered Party (if applicable)		
	
Undertaking by Scrutineer	
I undertake not to:	
(1)	unlawfully communicate any information about the vote of an elector acquired by me in the performance of my duties under the Electoral Act 1992 in a way that is likely to enable the identification of that elector; and	
(2)	interfere with or attempt to influence the vote of any elector; and	
(3)	communicate with any person in the polling place except so far as is necessary in the discharge of my duties.	
		
Signature of scrutineer			/          /