Ministry of Municipal Affairs	Nomination Paper - Form 1
Municipal Elections Act, 1996 (Sections 33, 35)

Instructions
A nomination paper may only be filed in person or by an agent; it may not be faxed or emailed. It is the responsibility of the person being nominated to file a complete and accurate nomination paper. Please print or type information (except signatures).

Nomination paper of a person to be a candidate at an election to be held in the following municipality

Nominated for the office of

Ward name or no. (if any)
n/a

Plummer Additional

Nominee's name as it is to appear on the ballot paper (subject to agreement of the municipal clerk) Last Name or Single Name	Given Name(s)

Nominee's full qualifying address within municipality
Suite/Unit No.	Street No.	Street Name	
Municipality	Province	Postal Code	
Mailing Address	Same as qualifying address
Suite/Unit No.	Street No.	Street Name	
Municipality	Province	Postal Code	
If nominated for school board, full address of residence within its jurisdiction
Suite/Unit No.	Street No.	Street Name	
Municipality	Province	Postal Code	
Email Address	Telephone No. (including area code)	Telephone No.2 (including area code)	
Declaration of Qualification
I, 	 , declare that I am presently legally qualified (or would be presently legally qualified if I were not a member of the Legislative Assembly of Ontario or the Senate or House of Commons of Canada) to be elected and to hold the office for which I am nominated.

Signature of Nominee	Date (yyyy/mm/dd)

Date Filed (yyyy/mm/dd)	Time Filed	Initial of Nominee or Agent	Signature of Clerk or Designate	
Certification by Clerk or Designate

Signature

Date Certified (yyyy/mm/dd)

I, the undersigned clerk of this municipality, do hereby certify that I have examined the nomination paper of the aforesaid nominee filed with me and am satisfied that the nominee is qualified to be nominated and that the nomination complies with the Act.

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9499P_E (2018/04)	© Queen's Printer for Ontario, 2018	Disponible en français