Please return a scanned copy of the completed form to: iro@electionz.com

APPLICATION FOR MARKED ELECTORAL ROLL
(Under section 68(6) of the Local Electoral Act 2001)

I,		
being a candidate in the following local body election:	
	(Issue name)	
for the		Council	
apply for a copy of the marked electoral roll and acknowledge that the data supplied to me will be used for election scrutiny purposes only. I undertake to ensure the information is not used for any other purpose or supplied to any other party for other than election scrutiny purposes.	

File type required:

Full Electoral Roll

Ward roll only (specify ward)

Frequency:

Daily

Weekly:	Preferred day

Other:	Specify

Date first file is required:		
Email address to send file:		

I confirm the charge for supplying these files is to be invoiced to:

Signed:		
Date:		

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