Request for a referendum vote

I, the undersigned, declare that I am a qualified voter entitled to be registered on the referendum list of the municipality (or of the area concerned by the above-mentioned by-law, resolution or ordinance, as the case may be) and request that a referendum vote be held on (this by-law, resolution or ordinance), in accordance with the Act respecting elections and referendums in municipalities (R.S.Q., c. E-2.2)