HomeMy WebLinkAboutForm 4 - Nomination Paper Fillable.21FORM4 Nomination Paper and Candidate's Acceptance
Local Authorities Election Act
(Sections 12, 21, 22, 23, 27, 28, 47,
68.1, 151, Part5.1)
Education Act (Sections 4(4), 74)
Note: The personal information on this form is being collected to support the administrative requirements of the local authorities
election process and is authorized under sections 21 and 27 of the Local Authorities Election Act and section 33(c) of the Freedom
of Information and Protection of Privacy Act. The personal information will be managed in compliance with the privacy provisions of
the Freedom of Information and Protection of Privacy Act. If you have any questions concerning the collection of this personal
information, please contact
Executive Assistant 403-794-2319
Title of the Responsible Official Business Phone Number
LOCAL JURISDICTION: ____________________ , PROVINCE OF ALBERTA
We, the undersigned electors of , nominate --------------------------Name of Local Jurisdiction and Ward (if applicable)
of
Candidate Surname Given Names
as a candidate at the election
Complete Address and postal code
about to be held for the office of
Office Nominated for
of
Name of Local Jurisdiction
Signatures of at least 5 ELECTORS ELIGIBLE TO VOTE in this election in accordance with sections 27 and 47
of the Local Authorities Election Act and sections 4( 4) and 7 4 of the Education Act (if applicable). If a city or a board
of trustees under the Education Act passes a bylaw under section 27(2) of the Local Authorities Election Act, then the
signatures of up to 100 electors eligible to vote may be required.
Complete Address and Postal Code
Printed Name of Elector of Elector Signature of Elector
LGS0753 Rev. 2019-10 Page 1 of 2
County of Newell
Councillor
County of Newell
Candidate's Acceptance
I, the above named candidate, solemnly swear (affirm)
•THAT I am eligible under sections 21 and 47 (and section 12, in the case of summer villages) of the Local
Authorities Election Act and sections 4( 4) and 7 4 of the Education Act (if applicable) to be elected to the
office·•THAT I am not otherwise disqualified under section 22 or 23 of the Local Authorities Election Act;
•THAT I will accept the office if elected;
THAT I have read sections 12, 21, 22, 23, 27, 28, 47, 68.1, and 151 and Part 5.1 of the Local Authorities
Election Act and sections 4( 4) and 7 4 of the Education Act (if applicable) and understand their contents;
•THAT I am appointing
Name, Contact Information or Complete Address and Postal Code and Telephone Number of Official Agent (if applicable)
as my official agent.
THAT I will read and abide by the municipality's code of conduct if elected (if applicable); and
THAT the electors who have signed this nomination paper are eligible to vote in accordance with the Local
Authorities Election Act and the Education Act and resident in the local jurisdiction on the date of signing the
nomination.
Print name as it should appear on the ballot
Candidate's Surname Given Names (may include nicknames, but not titles, i.e., Mr., Ms., Dr.)
SWORN (AFFIRMED) before me
at the of
in the Province of Alberta,
this day of , 20
Signature of Returning Officer or Commi ssioner for Oaths
or Notary Public in and for Alberta
(Also include printed or stamped name and expiry date)
RETURNING OFFICER'S ACCEPTANCE
Returning Officer signals acceptance by signing this form:
Signature of Returning Officer
Candidate's Signature
Commissioner for Oaths Stamp
IT IS AN OFFENCE TO SIGN A FALSE AFFIDAVIT OR A FORM THAT
CONTAINS A FALSE STATEMENT
LGS0753 Rev. 2019-10 Page 2 of 2