10. Citizenship status code: (State if your are a citizen by 1. Birth, 2. Descent, 3. Registration or 4. Non-citizen resident) ………………………………………………………………………………… 11. If non-citizen permanent resident:: (State residence permit number and/or number of years lived in Zimbabwe) ……………………………………………………………………………………. 12. National registration number ………………………………………………………………… 13. Occupation: …………………………………………………………………………………… 14. Postal address (in full) …………………………………………………………………………… 15. State constituency in which you wish to be registered: …………………………………………… 16. State reasons for requesting registration in a constituency where you are not resident: ………………………………………………………………………………………………………… . (if space is insufficient please attach a sheet containing reasons) 17. State address in full where you wish to be deemed to be resident in a constituency: ………………………………………………………………………………………………………. PART B TO BE COMPLETED BY REGISTRATION OFFICER ONLY 18. Voter number (national registration number) ……………………………………………………… 19. Block number ………………………………………………………………………………………. 20. Constituency ………………………………………………………………………………………… 21. District ……………………………………………………………………………………………… 22. Place of registration: …………………………………………………………………...…………… PART C DECLARATION BY CLAIMANT I declare that all the statements made in this claim are true to the best of my knowledge and belief and that I have not previously applied for registration on the Voters roll. Date: ……………………………….. Personal signature of claimant ……………���………. WARNING: SEVERE PENALTIES ARE IMPOSED FOR GIVING FALSE INFORMATION PART D - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - CERTIFICATE OF REGISTRATION AS A VOTER Serial No. This is to certify that …………………………………………………… has been registered as a Voter on the Voter’s Roll for the Constituency of …………………………………………………………………. Block number: ……………………………………………………………………………………………. National registration number: ……………………………………………………………………………. Place of registration: ……………………………………………………………………………………… Name of Registrar in print form: …………………………………………………………………………. Date: …………………………………………… Signature: ………………………………………. Form V3 - 16 -