Nomination Form
Each candidate must submit this form in person to Returning Officer before the close of nominations. / Council
Ward
(if applicable)
CANDIDATE DETAILS (please use BLOCK LETTERS) / OFFICE USE ONLY
Date and time lodged / ……/……/……… ………:……am/pm
Silent elector? / YES/NO
Title / Date of birth for
roll checking purposes
Given name/s (in full)
Surname (in full)
Address on
the voters’ roll
V / I / C / Postcode
Residential address
(if different from above)
Postcode
Postal address
(if different from above)
Postcode
BUSINESS HOURS / AFTER HOURS
Landline / (0 / ) / (0 / )
Fax / (0 / ) / (0 / )
Mobile phone
Email
* Please asterisk which of the above phone, fax or email details you can be contacted on at short notice.
Form in which candidate’s name is to appear on the ballot paper (clearly indicate capitalisation and accents).
Surname
Other name/s
CONTACT PERSON (The following details will be made available for public and media enquiries.)
Name
BUSINESS HOURS / AFTER HOURS
Landline / (0 / ) / (0 / )
Mobile phone
Email

Candidate’s signature……………………………………………………………Date ………/………/………

DD MM YYYY

continued over page

DECLARATION

I, ……………………………………………………………………………………, declare that: (please tick to affirm)

(write candidate’s name in full)
 / I apply to be a candidate for the office of Councillor for;
………………………………………………………… Ward / (strikethrough if ward does not apply)
(write name of council ward here)
………………………………………………………………….. Council at the election in …………… ;
(write name of council here) (YYYY)
 / I am qualified to be a candidate under the Local Government Act 1989;
 / I have read section 28 of the Local Government Act 1989 and confirm that I understand the requirements to be qualified as a candidate;
 / I am capable of becoming a Councillor under the Local Government Act 1989;
 / I have read sections 28, 28A, 28B, 29, and 30 of the Local Government Act 1989 and confirm that I understand the requirements of being capable of becoming a Councillor;
 / I am aware that it is an offence under section 52(2) ofthe Local Government Act 1989, to submit a nomination in breach of sections 70(2), (2A), (3), (4) or (5) of the Local Government Act 1989;
 / I have read section 52(2) of the Local Government Act 1989 and understand the requirements of section 52(2);
 / I am aware that it is an offence under the Local Government Act 1989 for a person who is not qualified to be a candidate and is not capable of being a Councillor to submit a nomination form;
 / I have not nominated as a candidate for more than one election of Councillors to be held on the same day.

To be signed by the candidate in the presence of the Returning Officer:

Candidate’s signature
……………………………………………… / Candidate’s name (please print)
………………………………………………… / Date
………/………/………
DD MM YYYY
Returning Officer’s signature
……………………………………………… / Returning Officer’s name (please print)
………………………………………………… / Date
………/………/………
DD MM YYYY
OFFICE USE ONLY: / Nomination fee ($250) received by /  cash /  bank cheque
Notes to candidates
  • On request, this form will be made available for public inspection in the election office. Candidate and telephone details for candidates enrolled as silent will be withheld from public inspection.

  • You must inform the person named as contact person that the contact details provided on this form will be made available for public and media enquiries.

  • Candidates are obliged to follow the law and should familiarise themselves with the contents of the Candidate Handbook.

  • Particular offences apply to local government elections and are prescribed in the Local Government Act 1989.

False declaration—Penalty: 120 penalty units.
A person who is required to make a written declaration by or under this Act or the regulations as a candidate, scrutineer or voter or as a person submitting a how-to-vote card must not knowingly make a declaration which is false.
Unlawful nomination—Penalty: Liable to a term of imprisonment not exceeding 2 years or to a fine not exceeding 240 penalty units.
If a person who is not qualified to be a candidate or is not capable of becoming a councillor submits a nomination the person is guilty of an offence.
This list is not exhaustive and further offences exist.