FOR RETURNING OFFICE USE ONLY 16/05 Registration of a Political Party Form 3 Elections Act Section 180 PLEASE PRINT IN BLOCK LETTERS FULL NAME OF PARTY REQUESTED EFFECTIVE DATE OF REGISTRATION (yyyy/mm/dd) PARTY ABBREVIATION LOGO ADDRESS FOR PARTY CORRESPONDENCE NAMES OF LEADER AND TWO (2) PRINCIPAL OFFICERS NAME OF LEADER RESIDENTIAL ADDRESS TELEPHONE #S E-MAIL NAME OF PRINCIPAL OFFICER OFFICER RESIDENTIAL ADDRESS TELEPHONE #S E-MAIL NAME OF PRINCIPAL OFFICER OFFICER RESIDENTIAL ADDRESS TELEPHONE #S E-MAIL OFFICIAL AGENTS(s) NAME RESIDENTIAL ADDRESS TELEPHONE #S E-MAIL NAME RESIDENTIAL ADDRESS TELEPHONE #S E-MAIL AUDITOR NAME RESIDENTIAL ADDRESS TELEPHONE #S E-MAIL ADDRESS OF WHERE BOOKS AND RECORDS OF ACCOUNTS ARE MAINTAINED FINANCIAL INSTITUTION TO BE USED AS DEPOSITORY FOR CONTRIBUTIONS INSTITUTION AND BRANCH LOCATION MAILING ADDRESS ACCOUNT NUMBER POSTAL CODE PLEASE FIND THE AUDITED FINANCIAL STATEMENTS ATTACHED, DATED WITHIN 60 DAYS OF THIS APPLICATION I DECLARE THAT THE POLITICAL PARTY’S PRIMARY PURPOSE IS TO FIELD CANDIDATES FOR ELECTION AS MEMBERS OF THE HOUSE OF ASSEMBLY (SECTION 180 OF THE ELECTIONS ACT). DATE (yyyy/mm/dd) PRINT NAME SIGNED BY THE LEADER OF THE APPLICATION PARTY ELECTIONS NOVA SCOTIA OFFICE USE ONLY - CONFIRMATION OF PARTY REGISTRATION OFFICE OF THE CHIEF ELECTORAL OFFICER EFFECTIVE DATE OF REGISTRATION (yyyy/mm/dd) APPROVED DATE DATE (yyyy/mm/dd) CHIEF ELECTORAL OFFICER FOR RETURNING OFFICE USE ONLY 16/05 Registration of a Political Party Form 3 Elections Act Section 180 SECTION 180(4) OF THE ELECTION ACT STATES: AN APPLICATION FOR REGISTRATION PURSUANT TO THIS SECTION MUST BE ACCOMPANIED BY A COMPLETE AND ACCURATE PETITION IN THE PRESCRIBED FORM, SIGNED BY NO FEWER THAN TWENTY-FIVE ELECTORS IN EACH OF TEN DIFFERENT ELECTORAL DISTRICTS, REQUESTING REGISTRATION OF THE POLITICAL PARTY. SIGNATORIES MAY BE CONTACTED BY THE CHIEF ELECTORAL OFFICER TO CONFIRM THEY ARE ELECTORS AS DEFINED IN THE ELECTIONS ACT. THIS FORM IS TO BE COPIED AS MANY TIMES AS NECESSARY. PLEASE PRINT CLEARLY – ENTRIES THAT ARE NOT DECIPHERABLE WILL BE REJECTED DATE NAME OF ELECTOR SIGNATURE OF RESIDENTIAL ADDRESS OF ELEC- ELECTORAL PHONE NUMBER E-MAIL ADDRESS NAME OF ATTESTING WITNESS SIGNATURE OF ATTESTING YYYY/MM/DD (PRINT) ELECTOR TOR, INCLUDING POSTAL CODE DISTRICT (PRINT) WITNESS NUMBER THIS CAN BE LOCATED THROUGH THE ELECTIONS NOVA SCOTIA WEBSITE (FIND YOUR ELECTORAL DISTRICT). PLEASE SEE DISTRICT NUMBERS AND DESCRIPTIONS ON NEXT PAGE. FOR RETURNING OFFICE USE ONLY 16/05 Registration of a Political Party Form 3 Elections Act Section 180 01 - Annapolis 27 - Halifax Citadel-Sable Island 02 - Antigonish 28 - Halifax Needham 03 - Argyle-Barrington 29 - Hammonds Plains-Lucasville 04 - Bedford 30 - Hants East 05 - Cape Breton Centre 31 - Hants West 06 - Cape Breton-Richmond 32 - Inverness 07 - Chester-St. Margaret’s 33 - Kings North 08 - Clare-Digby 34 - Kings South 09 - Clayton Park West 35 - Kings West 10 - Colchester-Musquodoboit Valley 36 - Lunenburg 11 - Colchester North 37 - Lunenburg West 12 - Cole Harbour-Eastern Passage 38 - Northside-Westmount 13 - Cole Harbour-Portland Valley 39 - Pictou Centre 14 - Cumberland North 40 - Pictou East 15 - Cumberland South 41 - Pictou West 16 - Dartmouth East 42 - Queens-Shelburne 17 - Dartmouth North 43 - Sackville-Beaver Bank 18 - Preston-Dartmouth 44 - Sackville-Cobequid 19 - Dartmouth South 5 - Sydney-Whitney Pier 20 - Guysborough-Eastern Shore-Tracadie 46 - Sydney River-Mira-Louisbourg 21 - Eastern Shore 47 - Timberlea-Prospect 22 - Fairview-Clayton Park 48 - Truro-Bible Hill-Millbrook-Salmon River 23 - Glace Bay 49 - Victoria-The Lakes 24 - Halifax Armdale 50 - Waverley-Fall River-Beaver Bank 25 - Halifax Atlantic 51 - Yarmouth 26 - Halifax Chebucto.