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Form 1A
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Application for Registration made on behalf of elector by a member of his household.
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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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I,
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(state your full name)
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of,
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(state your residential address including your land valuation assessment number)
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Surname
Maiden Name
Forename(s) (state your full name)
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I,
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(state the full name of person in respect of whom the applicant in being made ("the
applicant"))
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whose residential address is
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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 apply for his/her registration in the parlimentiary register of the
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(name of constituency living in)
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constituency, and I declare that have consent and authority of the applicant to
make this application on his/her behalf, and I further declare that the applicant
--
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(a) was born in
on the
day of
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in the year
;
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(state applicant's date of birth)
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(b) is a Commonwealth citizen,
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(c) possesses Bermudian status, and was granted, such on the
day of
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in the year
;
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(state applicant's date of grant)
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(d) does not possess Bermudian status, but was registered as an electoron 1 May,
1976.
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(e) is not registered in the parlimentiary register of any other constituency.
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(f) has not applied to be registered as an elector in any other constituency.
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(g) is not disqualified for registration as an elector.
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Email Address
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Your Signature
__________________________________________
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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