Trinbarjam Elections Commission

69 Brickdam Street Georgetown

Telephone Number: 206-3439
Email: trinbarjamelectionscommision@gmail.com

2019 Elections
Nomination Form

Please place a tick (√ ) in the appropriate boxes provided and use block letters when filling in
information.

A. Candidate’s Personal Information

● Full Name: Click or tap here to enter text. • Gender: Choose an item.

● Date of Birth: Click or tap to enter a date.

● Address:Click or tap here to enter text.
● Contact Numbers: Click or tap here to enter text. • Email Address: Click or tap here to enter text.

● ID Number: Click or tap here to enter text. • Passport Number: Click or tap here to enter text.

● Profession:Click or tap here to enter text. • Place of Employment: Click or tap here to enter text.
● Marital Status: Click or tap here to enter text.

B. Constituency Information
● Supported Party: (Full Name) Click or tap here to enter text.
(Acronym) Click or tap here to enter text.

● Constituency Contesting For:

I, the candidate named above, consent to my nomination and confirm that all information provided
is accurate.

Signature: …………………………………………………….

Date: …………………………………………………………….

Trinbarjam Elections Commission

C. Reference 1

● Full Name: Click or tap here to enter text.

● Address: Click or tap here to enter text.
● Contact Numbers: Click or tap here to enter text. • Profession: Click or tap here to enter text.
Signature……………………………………………….

D. Reference 2
E. Full Name: Click or tap here to enter text.
F. Address: Click or tap here to enter text.
G. Contact Numbers: Click or tap here to enter text. • Profession: Click or tap here to enter
text.
Signature……………………………………………….

H. Reference 3
● Full Name: Click or tap here to enter text.
● Address: Click or tap here to enter text.
● Contact Numbers: Click or tap here to enter text. • Profession: Click or tap here to enter text.
Signature……………………………………………….

✂----------------------------------------------------------------------------------------------------------------------------

RECEIPT OF PAYMENT
NOMINATION FEE

Receipt Number: ………………………….… Date: ……………………………………..

Name: ………………………………………………………………………………………
Amount Paid: ………………………………
Signature…………………............................

Trinbarjam Elections Commission