PERSONAL PARTICULARS

Commonwealth of Australia To the Electoral Registrar, Subdivision of

Please use BLOCK LETTERS only.

Please use blue or black ink only.

My name is

Surname

Please include all names by which you are generally known.

Christian or given names

Residential address—you can only be enrolled for your residential address. Please give your full address. If you live in a rural area show sufficient detail to identify your place of living.

I live at

Flat/Street number           Street/Road

Suburb/Town/Locality

Postal address—if the same as residential address put ‘As above’.

My postal address is

Postal address

Postcode

Your postal address will not appear on the roll.

My occupation is

Occupation

(delete one) and I am Male/Female

The remaining details are necessary for identification but will not appear on the roll.

I was born on

day month year                  Town

............ /......... /.......... / in

Country

Complete former address only if you have moved since your last enrolment.

My former address was

No.           Street                    Suburb/Town

State/Territory

Complete former name only if you have changed your name (for example by marriage) since your last enrolment

My former name was

Former name

DECLARATION

1 am entitled to enrolment because—

(a)      I am not under 18 years of age;

(b)      I have lived continuously in Australia for at least 6 months;

(c)      I am an Australian citizen or other British subject;

(d)     I have lived at my present address (or elsewhere within the Subdivision) for the period of 1 month immediately before the date of this claim,

Upon enrolment you will be entitled to vote at elections for the House of Representatives and the Senate.

and I claim enrolment for the Subdivision.

You must sign this declaration in the presence of a person who is enrolled, or entitled to be enrolled, on an electoral roll kept for the purposes of a House of Representatives election.

I declare that the statements made in this claim, including my personal particulars set out above, are true to the best of my knowledge and belief.

A person who is unable to sign his name in writing may make his mark as his personal signature.

.............................................................                        ........ /...... ./.......

Personal Signature of Claimant                                               Date

WITNESS

I saw this claim signed by the claimant and am satisfied that the statements

As the person to witness this claim you must be satisfied from personal knowledge or enquiry of the claimant or otherwise that the information declared is true.

contained in the claim are true.

I am enrolled, or entitled to be enrolled, on an electoral roll kept for the purposes of a House of Representatives election.

Name of witness in BLOCK LETTERS

Surname                      Christian or given names

You may not witness this claim unless you are able to sign your name in writing.

Full address of witness

Address

.............................................................                        ........ /...... /........

Signature of witness                                                                Date