Application for Nomination

This form should take approximately ten minutes to complete. By submitting this form you are not committing to anything at this stage, nor is the Party. Once you submit we will contact you to discuss next steps and/or what type of candidacy may work best for you. If you have any questions you can call the Secretary of the Nominations committee, Suzette Luyken via suzetteluyken@legalisecannabis.org.au

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Nomination Type Selected

PERSONAL DETAILS

Surname

Given Names

Have you been known by any other names?

Please give details regarding these other names

Residential Address

Street Address Address Line 2 Suburb State/Territory Post Code

Home Phone

Mobile Phone

Age

Date of Birth

Country of Birth

Occupation

Age of all children (if any)

Years resident in Australia

Years resident in your state

Are you of Aboriginal or Torres Strait Islander origin?

Do you come from a culturally or linguistically diverse background?

Please give details regarding your background in relation to the previous question:

DETAILS OF POLITICAL ACTIVITIES

Have you ever been a member of a political party (or parties) other than Legalise Cannabis?

Please provide more details in relation to the "Yes" reponse to the previous question

Are you a current Legalise Cannabis party member?

How long have you been a member?

GENERAL

The following questions identify any real or potential issues in relation to section 44 of the Constitution. For more information: https://www.aec.gov.au/About_AEC/Publications/backgrounders/constitutional-disqual-intending-candidates.htm

Do you hold or have you ever held or been entitled to citizenship or nationality other than Australia?(Required)

Do you hold any office under the Australian government or the government of a State or Territory or any government authority or Agency or local government or are you employed by any of the above?(Required)

Please provide more information in relation to your response to the last question:

Legalise Cannabis Australia respects the privacy of potential candidates however there are some matters relating to the personal and financial affairs of candidates that do require disclosure. These do not necessarily rule you out as a candidate. Issues to be considered are whether you have a criminal record, owe monies to the Australian Tax Office, ever been a bankrupt, been under investigation by the ASIC, ATO or similar, have a financial interest or shareholding in any company or enterprise that could be perceived as a conflict of interest; or any other issue in your past or present that if it were made public could be damaging to the Party?(Required)

Do not make any disclosure in writing on this form.

Learn about our three-stage plan for the legalisation of Cannabis in Australia