Form V.21 ELECTORAL ACT [CHAPTER 2:13] ________________ CERTIFICATION OF ELIGIBILITY OF MEMBER OF THE PUBLIC SERVICE FOR NOMINATION AS A CANDIDATE AND FOR ELECTION AS A COUNCILLOR ________________ Surname: ………………………………………………………………………………………………. First names: ……………………………………………………………………………….…………… Citizenship: ………………………………………………………………………………���…………. Residential address in full: …………………………………………………………………………… Postal address in full: ……………………………………………………………………………….. Occupation: ………………………………………………………………………………………. Employment code number: ……………………………………………………………………… Ministry or Government department: …………………………………………………………… Department and section numbers: ……………………………………………………………… Position/Title: …………………………………………………………………………………… Job description: ………………………………………………………………………………… Comments of head of department: ……………………………………………………………… Recommendation of head of department: …………………………………………………… …………………………………………………………………………………………….…. Secretary’s recommendations: …………………………………………………………….… …………………………………………………………………………………………….… Recommendation of Public Service Commission: ……………………….……………….. Signed ……………………………….. Date ……………………………….. (Head of Ministry) Signed ……………………….………… Date ……………………….……… (for Public Service Commission) - 62 -