Application to Amend the Voters' List
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Application to Amend the Voters' List
8/31/2018 10:52:25 AM
8/31/2018 10:47:17 AM
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APPLICATION TO AMEND THE VOTERS' LIST <br />Municipal Elections Act, 1996 (s.17, s.24) -City of Kitchener <br />Check only one D Add applicant's name to List <br />El Correct applicant's information on List <br />❑ Delete applicant's name from List <br />Year Month Da <br />Name of Applicant Canadian Citizen ❑ Date of Birth <br />Last Name First Name Middle initial or Name <br />Qualifying Address on Voting Day ❑ Commercial property <br />Street Number & Name Apt # Postal Code (If no apt #. indicate <br />floor level - eg. <br />basement, 1stfl. <br />, etc. <br />30 12 <br />Roll Number (If known) Ward # Voting <br />Subdivision <br />Previous Qualifying Address (If applicable) <br />At qualifying address, Applicant is: <br />❑Owner since <br />❑Tenant since <br />Other since <br />❑S po use <br />❑Unqualified (deleted name only) <br />At previous address, Applicant was: <br />KITCHENER I I <br />Owner <br />Street Number & Name Apt # Postal Code (If no apt #. indicate ❑Tenant <br />floor level - eg. ❑Other <br />basement, 1stfl., etc.) ❑Spouse <br />um <br />Subdivision <br />Current mailing address of applicant (If different than Qualifying address above) At mailing address, Applicant is: <br />KITCHENER I ❑Owner <br />Street Number & Name Apt # Postal Code ❑Tenant <br />❑Other <br />School Support ❑Spouse <br />❑ Applicant is Roman Catholic (includes Greek & Ukrainian Catholic) <br />Applicant has French Language Education Rights <br />Applicant wishes to be an elector for the following school board <br />English -Public (Anyone can support English -Public) French -Public (Must have French Language Education Rights) <br />❑ English -Separate (Must be Roman Catholic) ❑ French -Separate (Must be Roman Catholic & have French Language <br />Education Rights) <br />If this application is to correct or remove the Applicant's name from the Voters' List, state the necessary changes: <br />I, the undersigned, hereby declare that I am a Canadian citizen, that I have attained the age of eighteen (18) on or before Voting Day, and that on <br />Voting Day, I am entitled to be an elector in accordance with the facts or information submitted on this form, and that I understand the effect <br />hereof. I hereby apply to have my name included or amendments made on the Voters' List in accordance with such facts or information. <br />Signature of Applicant Date <br />If this signed application is submitted by an agent of the applicant, the agent shall declare as follows: <br />I hereby declare that the applicant has appointed me as her/his agent and on her/his behalf I file this application. <br />(Name of Agent) (Signature of agent) <br />(Address of Agent) (Telephone no.) <br />This information is collected under authority of s.17 and s.24 of the Municipal Elections Act and s.15 and s.16 of the Assessment Act and will be used to <br />determine voter eligibility. <br />Certificate of Approval [to be completed by Clerk or designate (e.g. DRO)] <br />❑ Approved ❑ Refused (state reason) <br />I hereby certify that the Voters' List for said voting subdivision in this <br />municipality shall be amended in accordance with the statement of facts <br />or information contained herein. <br />Signature of Clerk or Designate <br />Date <br />Application to be filed in person by Applicant or Agent at: City Clerk, City Hall, 2nd Floor, 200 King St W., Kitchener Ontario <br />N2G 4G7 or at a voting location on Election Day <br />
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