The question to be submitted to the voters for the adoption of any of the optional plans of government authorized by this act shall be submitted in the following form or such part thereof as shall be applicable:
"Shall ........................................ of the
(insert name of plan)
Optional Third Class City Charter Law providing for
........................... councilmen to be elected
(insert number)
at large be adopted by the city of .........................."
(insert name of city)
53 P.S. § 41214