NOMINATION FORM FOR NATIONAL ASSEMBLY CANDIDATES
ELECTORAL ACT [Chapter 2:13]
(Section 46(1))
____________
NOTE: Aspiring candidate should produce:1.
2.
a birth certificate together with National Registration Identity Card. Please attach photocopies of the said
documents.
a recent passport-size photograph.
_______________
We the undersigned voters registered in the ……………………………………………………….constituency,
hereby nominate:
..…………………………………………………………….. ………………….... ………………………………
(full name in block letters)
National Registration Number ………………………………………………………… of …………………….
…………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………….
(full address in block letters)
as a candidate to represent the said constituency in the National Assembly.
(In terms of section 46(1)(a) of the Electoral Act, the form must be signed by not fewer than five persons
who are registered on the voters rolls for the constituency. In terms of section 46(1)(a)(e), the nomination
form must be accompanied by two copies of the electoral code of conduct signed by the candidate or his
or her chief election agent, which copies may be obtained on nomination day from the nomination
officer.) Law Reviser
Page 1 of 7
1.
Full Names …………………………………………………………………………………………………………
(Block Letters)
National Registration Number……………………………………………………………………………………..
Signature……………………………………………………….
Date………………………………...
Signed in the presence of…………………………………………………………………………………………..
(Candidate/Chief Election Agent/Authorized Representative)
2.
Full Names …………………………………………………………………………………………………………
(Block Letters)
National Registration Number……………………………………………………………………………………..
Signature……………………………………………………….
Date………………………………...
Signed in the presence of…………………………………………………………………………………………..
(Candidate/Chief Election Agent/Authorized Representative)
3.
Full Names …………………………………………………………………………………………………………
(Block Letters)
National Registration Number……………………………………………………………………………………..
Signature……………………………………………………….
Date………………………………...
Signed in the presence of…………………………………………………………………………………………..
(Candidate/Chief Election Agent/Authorized Representative)
4.
Full Names …………………………………………………………………………………………………………
(Block Letters)
National Registration Number……………………………………………………………………………………..
Signature……………………………………………………….
Date………………………………...
Signed in the presence of…………………………………………………………………………………………..
(Candidate/Chief Election Agent/Authorized Representative)
5.
Full Names …………………………………………………………………………………………………………
(Block Letters)
National Registration Number……………………………………………………………………………………..
Signature……………………………………………………….
Date………………………………...
Signed in the presence of…………………………………………………………………………………………..
(Candidate/Chief Election Agent/Authorized Representative)
Page 2 of 7
6.
Full Names …………………………………………………………………………………………………………
(Block Letters)
National Registration Number……………………………………………………………………………………..
Signature……………………………………………………….
Date………………………………...
Signed in the presence of…………………………………………………………………………………………..
(Candidate/Chief Election Agent/Authorized Representative)
7.
Full Names …………………………………………………………………………………………………………
(Block Letters)
National Registration Number……………………………………………………………………………………..
Signature……………………………………………………….
Date………………………………...
Signed in the presence of…………………………………………………………………………………………..
(Candidate/Chief Election Agent/Authorized Representative)
Note – Extra nominations may be made in anticipation of any nominator being found to be disqualified from
making any nomination.
Page 3 of 7
DECLARATION BY OR ON BEHALF OF CANDIDATE
………………………………………………………………………………………………………………..
(Full name of candidate, block letters)
……………………………………………………………………………………………………………….
(address of candidate, in block letters)
Candidate’s telephone number: …………………………………………………………………………….
I certify that:
1.
2.
3.
4.
the candidate is enrolled as a voter in the ……………………………………………………………………..
constituency,
the candidate is not disqualified for election in terms of paragraph 2 of the Fourth Schedule to the new
Constitution,
each of the persons nominating the candidate signed this nomination paper in the presence of the candidate or
his or her chief election agent or his or her authorized representative,
the candidate accepts the nomination as candidate for election to Parliament.
Date: ………………………………. Signature: …………………………………………………………………………...
(Candidate/Candidates Chief Election Agent)
DISTINCTIVE SYMBOL AND PARTY NAME ABBEVIATION
(This part is to be completed if the candidate wishes a distinctive symbol and/or Party identification to appear on
the ballot)
1.
Distinctive Symbol
The candidate wishes the following symbol to appear on the ballot paper in conjunction with his/her name:
(Show drawing of symbol here)
Short description of symbol: …………………………………………………………………………………..
…………………………………………………………………………………………………………………
2.
Party Identification
The candidate will be standing for or be sponsored by the following Party:
…………………………………………………………………………………………………………………
(Show drawing of symbol here)
(Full name of Party in block letters)
and wishes the following abbreviation of the Party’s name to appear on the ballot paper in conjunction with
Page 4 of 7
his/her name:……………………………………………………………………………………………………..
(block letters)
Signature: ……………………………………………………
Candidate*/Candidate’s Chief Election Agent*
3.
Party authorization (to be completed by at least two designated political party office-bearers if the candidate
has indicated that he/she wishes the abbreviation of a party’s name to appear on the ballot paper in conjunction
with his/her name)
We………………………………………………………………………………………………………………(1)
(full names)
…………………………………………………………………………………………………………………..(2)
being the …………………………………………………………………………………………………………..
(state offices held)
of the ………………………………………………………………………………………………………………
(full name of political party)
and, as such, duly authorized in terms of the constitution of the party, certify that the candidate to whom this
nomination paper relates will stand for, or be sponsored by, the party.
Date…………………………………………………..……………
Signature……………………………………………………………(1)
Signature……………………………………………………………(2)
* Delete whichever does not apply.
Note: This form must be accompanied by a passport-sized colour photograph of the candidate.
Page 5 of 7
FOR
FOR OFFICE
OFFICE USE
USE ONLY
ONLY
____________
____________
Name of
of Checkers:
Checkers: 1.……………………………………………………I.D.
1.……………………………………………………I.D. No.
No. ………………………….
………………………….
Name
(Print)
(Print)
2.…………………………………………………….I.D.
2.…………………………………………………….I.D. No.
No. ………………………….
………………………….
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No.
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____________
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____________
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3.……………………………………………………I.D. No. …………………………..
Name of Name
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A.
A. This
This nomination
nomination paper
paper is
is accepted/rejected.
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Presiding
Presiding Officer:
Officer: …………………………………………………………
………………………………………………………… I.D.
I.D. No.:
No.: ……………………….
……………………….
(Print
full
names)
(Print full names)
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paper
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Signature:
Signature: ……………………………………………………………………………Date:
……………………………………………………………………………Date: …………………
…………………
Presiding
Officer:
…………………………………………………………
I.D.No.:
No.:I.D.
……………………….
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……………………….
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B.
B. This
This nomination
nomination paper
paper is
is rejected
rejected because:
because:
Signature:
……………………………………………………………………………Date:
…………………
Signature:
……………………………………………………………………………Date:
Signature:
……………………………………………………………………………Date:
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……………………………………………………………………………Date:
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……………………………………………………………………………Date:
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……………………………………………………………………………Dat
………………………………………………………………………
…………………
…………………
…………………
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………
 Signature:
Insufficient
nominators
Insufficient
nominators
 Candidate
not
sponsored
by
given
political
Party.
Candidate not sponsored by given political Party.
 Candidate
Candidate not
not registered
registered
 Failure
Failure to
to pay
pay nomination
nomination fees
fees
 nomination
Any
other
state
B.
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nomination
paper
rejected
because:
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…………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………………
Presiding
Presiding officer:
officer: ……………………………………………………………
…………………………………………………………… I/D
I/D Number:
Number: ………………………
………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………………
(Print
full
names)
(Print full names)
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………………
Signature:
…………………………………………………….
Date
Signature:
…………………………………………………….
Date ………………………
……………………… Time
Time ……………….
……………….
Presiding
officer:
……………………………………………………………
I/DNumber:
Number:
………………………
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officer: ……………………………………………………………
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officer:
……………………………………………………………
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officer: ……………………………………………………………
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officer: ……………………………………………………………
officer: ……………………………………………………………
I/D Number:
I/D
Number:
………………………
I/D ………………………..
Number:
………………………
I/D Number:
………………………
I/D Number:
………………………
I/D Number:
……………
I/D Nu
……
Candidate:
…………………………………………………………………I/D
Candidate:
…………………………………………………………………I/D
Number:
………………………..
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full
names)
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………………………
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……………….
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…………………………………………………….
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…………………………………………………….
Signature:
…………………………………………………….
Signature:
…………………………………………………….
Signature:
…………………………………………………….
Signature:
…………………………………………………….
Date…………………………………………………….
………………………
Date
Date ………………………
Date
Time………………………
……………….
Date
Time
………………………
……………….
Date
Time………………………
……………….
Date
Time…………………
………………
Time ………
Ti
Signature:
…………………………………………………….
Date
……………………….
Time………………
Signature:
…………………………………………………….
Date………………………
……………………….
Time………………
Page 6
6 of
of 7
7
Page
Candidate:
…………………………………………………………………I/D
Number:Number:
………………………..
Candidate:
Candidate:
…………………………………………………………………I/D
Candidate:
…………………………………………………………………I/D
Candidate:
…………………………………………………………………I/D
Candidate:
…………………………………………………………………I/D
Candidate:
…………………………………………………………………I/D
Candidate:
…………………………………………………………………I/D
…………………………………………………………………I/D
Number: Number:
………………………..
………………………..
Number:
………………………..
Number:
………………………
Number:
………………
Num
……
(Print
full
names)
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names)
full
(Print
names)
full(Print
names)
full(Print
names)
full(Print
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full(Print
names)
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Signature:
…………………………………………………….
Date……………………….
……………………….
Time………………
Signature:Signature:
…………………………………………………….
Signature:
…………………………………………………….
Signature:
…………………………………………………….
Signature:
…………………………………………………….
Signature:
…………………………………………………….
Signature:
…………………………………………………….
Date…………………………………………………….
……………………….
Date
Date ……………………….
Date
Time………………
……………………….
Date
Time………………
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Date
Time………………
……………………….
Date
Time………………
…………………
Time………
T
Page 6 ofPage
Page
7 66of
of
Page
77 6 ofPage
7 6 ofP
PROHIBITED SYMBOLS
Electoral Act Chapter 2:13
Section 146
1. Lion
2. A bird of prey
3. A rhinoceros
4. A laurel wreath
5. A leopard
6. A cheetah
7. An owl
8. A sword
9. A griffon
10. A cobra
11. A secretary bird
12. A flaming torch
13. An axe
14. An elephant
15. A buffalo
16. A flame lily
Page 7 of 7