PART C DECLARATION BY CLAIMANT I declare that the statements made in this application are true to the best of my knowledge and belief and request that my name be transferred to the appropriate 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 V4 ELECTORAL ACT [CHAPTER 2:13] (Section 25) _______________ APPLICATION BY REGISTERED VOTER FOR TRANSFER FROM ONE CONSTITUENCY TO ANOTHER OF WHICH HE IS NOT RESIDENT ________________ In terms of the proviso to section 25(1) of the Act, a claimant may only transfer his or her registration to a constituency in which he or she is not resident if he or she intends to be a candidate for election as a member of Parliament in that constituency. _______________ THIS FORM MUST BE COMPLETED IN BLOCK LETTERS PART A 1. Type of registration code: 2. Surname …………………………………………………………………………………………….. 3. Forenames ………………………………………………………………………………………….. 4. Former names (if changed) ………………………………………………………………………… 5. Sex ………………………………………………………………………………………………….. 6. Date of Birth ………………………………………………………………………………………… - 18 -