PETITION

To the Legislative Assembly of Victoria

The Petition of

(insert here the names or descriptions of the petitioner or petitioners, such as residents of Victoria or residents of [name of town, region or electorate in Victoria])

draws to the attention of the House

or

points out to the House

(insert here the circumstances of the issue)

The petitioners therefore request that the Legislative Assembly of Victoria

(insert here the request of the petitioners, showing clearly the nature of the remedy or action requested)

NAME ADDRESS SIGNATURE