7. Place of Birth: (enter town, farm, mine, resettlement area or village and chief, if communal land)……………………………………………………………………………………………… 8. District of Birth …………………………………………………………………………………… 9. Country of Birth …………………………………………………………………………………… 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. State the Constituency in which you are presently registered …………………………………… 15. Present residential address (in full): (Communal dwellers must give name of village, headman and chief) ……………………..………………………………………………………………………. 16. Postal address (in full): …………………………………………………………………………… PART B TO BE COMPLETED BY REGISTRATION OFFICER ONLY 17. Voter number (national registration number): ……………………………………………………… 18. Deleted from (Constituency): ……………………………………………………………………….. 19. Forwarded to (Constituency): ……………………………………………………………………… 20. Old Block number: …………………………………………………………………………………. 21. New Block number: …………………………………………………………………………………. 21. District ……………………………………………………………………………………………… 22. Place of registration: …………………………………………………………………...…………… PART C DECLARATION BY CLAIMANT I, the undersigned do hereby declare that I am residing at the residential address set out above and request that my name be transferred to the appropriate rolls. Date: ……………………………….. Personal signature of claimant ………………………. WARNING: SEVERE PENALTIES ARE IMPOSED FOR GIVING FALSE INFORMATION PART D - 19 -