Nomination for Mayor or
Councillor
For Candidates NOT Endorsed by a Registered
Political Party
|
Ipswich City
(insert name of Local Government Area / Division No. /
Ward)
|
hereby nominate |
URSULA JANE MONSIEGNEUR
(name of candidate)
|
Surname | Given name(s) |
Enrolled address
(not to be published)
|
Date of birth
(not to be published)
|
Signature
(not to be published)
|
Office use |
---|---|---|---|---|---|
MONTGOMERY | CHRISTOFER BRIAN | ||||
BAILEY | ROSEMARY | ||||
BAILEY | VIOLET LILY ROSE | ||||
ALBURY | TERRENCE WAYNE | ||||
BYRNE | ANTHONY PATRICK | ||||
LYNCH | KERRI ANNE | ||||
RADKE | CHRISTINE MARIA | ||||
WALKER | DONALD BLAISE | ||||
SMYTHE | HELEN DOROTHY | ||||
Nomination for Mayor or
Councillor
For Candidates NOT Endorsed by a Registered
Political Party
|
Schedule of Information for |
URSULA JANE MONSIEGNEUR
|
Name of financial institution (not to be published)
|
BSB
(not to be published)
|
Account number
(not to be published)
|
Account name
(not to be published)
|
---|---|---|---|
Nomination for Mayor or
Councillor
For Candidates NOT Endorsed by a Registered
Political Party
|
I am contesting this election as a member of the |
Name of financial institution (not to be published)
|
BSB
(not to be published)
|
Account number
(not to be published)
|
Account name
(not to be published)
|
---|---|---|---|
I have successfully completed the mandatory training required by s26(2) of the Local Government Electoral Act 2011 in the last 6 months. |
The Unique ID number I received at the conclusion of the training is |
11476387
|
Name of party/organisation | Address of party/organisation | Date of membership | Date membership ceased (if applicable) |
---|---|---|---|
Australian Labor Party | 1/16 Peel St, South Brisbane | 10/03/2014 | |
National Tertiary Education Union | 1/4 Briggs St, Taringa, QLD | 21/04/2016 | |
QLD Nurses & Midwives Union | 106 Victory St, West End, QLD | 04/08/2016 | |
I have not been a member of any registered political party or trade or professional organisation at any time over the past 12 months, nor am I currently such a member. |
Nature of arrangement | Size of arrangement (i.e. medium-sized or large-sized) |
---|---|
Nomination for Mayor or
Councillor
For Candidates NOT Endorsed by a Registered
Political Party
|
Name of close associate & nature of relationship with candidate | Address of close associate (not to be published) | Nature of arrangement | Size of arrangement (i.e. medium-sized or large-sized) |
---|---|---|---|
I have not been a party to any contractual arrangement with the council (for which I am nominating) at any time in the past 12 months, nor am I currently a party to such an arrangement. I also confirm that my close associates are not and have not been a party to any contractual arrangement with the council at any time in the past 12 months. |
Nature of process |
---|
Name of close associate & nature of relationship with candidate | Address of close associate (not to be published) | Nature of process |
---|---|---|
I have not been a party to any contractual process with the council (for which I am nominating) at any time over the past 12 months, nor am I currently a party to such a process. I also confirm that my close associates are not and have not been a party to any contractual process with the council at any time in the past 12 months. |
Nomination for Mayor or
Councillor
For Candidates NOT Endorsed by a Registered
Political Party
|
Nature of applications or representations |
---|
Name of close associate & nature of relationship with candidate | Address of close associate (not to be published) | Nature of applications or representations |
---|---|---|
I am not currently a party to any outstanding applications or representations which were not decided before this nomination is made. I also confirm that my close associates are not parties to any outstanding applications or representations which were not decided before this nomination is made. |
I, |
URSULA JANE MONSIEGNEUR
|
(the candidate) |
Signature of candidate | Date |
(dd/mm/yyyy)
|
Nomination for Mayor or
Councillor
For Candidates NOT Endorsed by a Registered
Political Party
|
Title |
MRS
|
Family name |
MONSIEGNEUR
|
Given name |
URSULA JANE
|
Other names | Date of birth |
|
Gender |
Female
|
Occupation |
NURSE EDUCATOR
|
Enrolled address | |
Postal address (if different) |
Name to appear on ballot paper |
Ursula MONSIEGNEUR
|
Contact information will be published on the Commission's website. If you do not wish some or all of the contact details to appear on the web, please indicate by ticking the "No" boxes. |
Release publicly?
(tick if No)
|
Family name |
MONSIEGNEUR
|
Given name |
URSULA JANE
|
||
Postal address |
PO BOX 3214, WEST IPSWICH, QLD 4305
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Email address |
Nomination for Mayor or
Councillor
For Candidates NOT Endorsed by a Registered
Political Party
|
I, |
URSULA JANE MONSIEGNEUR
|
, the candidate in the nomination, |
for the Local Government Area / Division / Ward of |
Ipswich City
|
I started campaigning for this election prior to nomination. I started campaigning on |
|
1. |
I am enrolled on the electoral roll for an address within the Local Government Area |
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2. |
I am an Australian Citizen (please tick one box only and complete appropriate details):
(dd/mm/yyyy)
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3. |
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4. | I have completed and signed the attached Schedule of Information |
Signature of candidate | Date |
(dd/mm/yyyy)
|