I [name of person] do [solemnly affirm] [swear] that:

I am qualified to hold the office of [Mayor] [Councillor] for the District North Vancouver to which I have been elected;
I have not by myself or any other person knowingly contravened the Local Government Act respecting vote buying or intimidation in relation to my election to the office;
I will faithfully perform the duties of my office and will not allow any private interest to influence my conduct in public matters;
as required by the Local Government Act I will disclose any direct or indirect pecuniary interest I have in a matter and will not participate in the discussion of the matter and will not vote in respect of the matter.