Nomination for election of Board Members held on ____________________________

I, the undersigned _____________________________________________________
Being the representative of the (insert name of council)
do hereby nominate (insert name of councillor in full)
as a candidate for election to the following position:

[ ] President
[ ] Board member for the (insert name of region) region
(Mark with an ‘X’ the election for which the candidate is nominated)

Signature _______________________________________________________

And I, the above-named (insert name in full)
consent to the nomination and declare that I am the appointed
representative of (insert name of council)

Signature _______________________________________________________

A separate nomination form must be completed and delivered to the Returning Officer for each election for which a candidate is to be nominated.