FORM 11

[See Rule 21(4) ]

Revocation of Appointment of Polling Agent


Election of Councillors to the Corporation of the City of …………………… ….. from the ………………………...*ward


To:
The Presiding Officer,
………………………..
………………………..
………………………..
………………………..


I, …………….……………. a Candidate / ** Election Agent of ………………..at the above election hereby revoke the appointment of Polling Agent………………………. At the Polling Station No……………………at……………………..(Place)

Place :  
Date :
  Signature of Candidate / Election Agent

* Appropriate particulars of the Election to be inserted.

** Score off the inappropriate alternative