Form V.12 OBVERSE ELECTORAL ACT [CHAPTER 2:13] (Section 71(2) (a)) _______________ PARLIAMENTARY AND PRESIDENTIAL ELECTIONS: APPLICATION FOR A POSTAL BALLOT _______________ To: The Chief Elections Officer Private Bag 7782, Causeway. I, ....................................................................................................................................................... (full name in block letters) National Registration card*/Birth certificate*/Voter certificate* number ........................................... .......................................................................................................................................................... hereby apply for a postal ballot paper to enable me to vote at the forthcoming election in the … .......................................................................................................................................................... constituency. I declare that the answers given to the following questions are true and correct. Date and place ................................................................................................................................... ......................................................................... (Signature of applicant) Signed before me at the place and dates stated above ......................................................................... (Signature of witness) ............................................................................................................................................. (Qualifications of witness— see paragraphs 3(1) and (2) overleaf) 1. In which constituency are you registered as a voter? 2. YES/NO Are you now living in your constituency? (Delete whichever does not apply) 3. If you have answered “No” to question 2 above state the date you left. 4. Grounds on which claim for postal vote is based. (State which of the relevant grounds mentioned in paragraph 2 overleaf applies) 5. Important: Address to which postal ballot-paper is to be dispatched. *Delete whichever does not apply - 33 - Day Month Year