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