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Form 1
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Application for Registration
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After you have completed and printed this application form, sign and forward
it to the Parliamentary Registry Office by fax at 292-0207 or
via mail to P.O. Box HM 3272, Hamilton HM PX or by hand to #60 Reid Street, Hamilton.
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Surname
Maiden Name
Forename(s) (state your full name)
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I,
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House/Building Name
Apartment # or Name
House/Street #
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of,
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Road/Street Name
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Parish
Postal Code
Assessment #
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(state full residential address)
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hereby applies to be registered in the parlimentiary register of the
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(name of constituency living in)
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constituency, and I declare that
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(a) I was born in
on the
day of
,
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in the year
;
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(state date of your birth)
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(b) I am a Commonwealth citizen,
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(c) I possess Bermudian status, and I was granted Bermudian status on the
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on the
day of
, in the year
;
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(state date of grant)
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(d)I do not possess Bermudian status, but I was registered as an electoron 1 May,
1976.
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(e) I am not registered in the parlimentiary register of any other constituency.
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(f) I have not applied to be registered as an elector in any other constituency.
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(g) I am not disqualified for registration as an elector.
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Email Address
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Applicant Signature
_____________________________________
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Telephone No.
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Dated
_______________________
Home:
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Business:
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For office use only
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Registered By
_____________________________________
Dated
_______________________
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Click Here to Read Important Notes
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Warning: A person who knowingly makes
a statement which is false in a material particular or submits any document in support
of the application which is false in a material particular or which has been altered
without lawful authority is guilty of an offence and liable to 12 months imprisonment
or a fine of $500 or both.
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