| | | | |
| Name of Group __________________________________________________________________________ |
| | __ | IN FAVOUR OF THE QUESTION |
| | __ | OPPOSED TO THE QUESTION |
| | Designated Representative: |
| Name: | ______________________________________________ |
| Address: | ______________________________________________
______________________________________________ |
| Telephone # | ______________________________________________ |
| Date Registered: _________________ | __________________________ Returning Officer |
| I, the undersigned, designated representative of __________________________________ (group’s name),
a registered group of electors, nominate the following as the group’s agent with authority to represent the group in the manner provided by the Municipal Government Act at Polling Station Number _________ for the plebiscite being held on ____________________, _______, in the ___________________ of ____________________ (name of municipality) |
| |
_________________________________
(name of agent) |
_________________________________
(address of agent) |
| |
| Dated: ___________________ , Nova Scotia, this ________ day of _____________, ______ .
|
| |
| |
________________________________
Signature of Designated Representative |
| |
| ************************************************************************************** |
| |
| I, the Returning Officer for the plebiscite being held on __________________, _____ appoint the person named above as
agent of _______________________ (group’s name) with authority to represent the group in the
manner provided by the Municipal Government Act at Polling Station Number ____________ for the plebiscite. |
| | _________________________________
Signature of Returning Officer |