MELBOURNE CITY COUNCIL

REQUEST FOR GROUPING ANDGROUP NAME

Closes 12 noon22 September 2016

To the Returning Officer

We, being candidates for the office of Councillor at the Melbourne City Council elections, request that our names be grouped on the ballot paper and printed in the following order under the specified group name.

Order / Write Ballot Paper Name (surname first) /
Signature
1
2
3
4
5
6
7
8
9
GROUP NAME
No more than six words.

The Group Representative, (i.e. the first-named candidate in the group), must sign a declaration under (i), (ii) or (iii) and provide supporting evidence (if applicable) that the group is authorised to use the requested name.

(i)The group name requested implies an association with a Registered Political Party.

I declare that the group is authorised to use this name and I provide written authorisation below from the Registered Officer of the Registered Political Party.

Signed ...... Group Representative

Authorisation of Registered Officer of Political Party

I, ...... authorise the use of the

group name proposed on this form. Date......

Name of Registered Officer......

Name of Political Party......

(ii)The group name is the same as a group name used at the previous Melbourne City Council elections, or implies an association with a person or organisation.

I declare the group is authorised to use this name and I have evidence supporting our authority.

Signed ...... Group Representative

(iii)The name requested is a name other than described in (i) or (ii).

I declare that the group has made enquiries and is unaware of any other person, organisation, group or team that has claim to this name.

Signed ...... Group Representative

False Declaration - Penalty

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.

120 penalty units

Contact details of Group Representative (block letters please)

NAME
ADDRESS
PHONE / MOBILE
CONTACT NUMBER FOR
RO Use Only
Declaration signed
Supporting evidence copied and attached to this form
Date and time received ..../..../...... am/pm
Comments
......
......
......

M321MCC Victorian Electoral Commissiona