2864

THE NEW ZEALAND GAZETTE.

SCHEDULE.

[Front.]

[Form No. (1). APPLICATION FOR REGISTRATION BY PERSON OTHER THAN A SEAMAN.

Electoral District of .

I HEREBY apply to have my name entered on the Electoral Roll of the above district, and I declare that the statements made in this application, including those set forth on the back hereof, are true to the best of my knowledge and belief.

(1.) I am not under the age of twenty-one years.

(2.) I am a British subject by BIRTH; or

(3.) I am a British subject by NATURALIZATION [Strike out statement that IN NEW ZEALAND. does not apply.]

(4.) I have resided in New Zealand for twelve months.

(5.) I have resided in the above district for a period of not less than three months immediately preceding the date of this application.

(6.) My name is on the Electoral Roll for [If not already enrolled strike out this statement.]

(7.) My address and occupation on that Electoral Roll are [If not already enrolled strike out this statement.]

Signature of Applicant:

Signed and declared by the Applicant, this day of , 192 , before me—

Signature of Witness : [Registrar, or Deputy Registrar, or Authorized Agent of Registrar, or Justice, or Postmaster, or an Elector of THE District.]

Address of Witness :

NOTE.—If the applicant cannot write, his mark must be witnessed by a Justice, or a Postmaster, or a Registrar, or some person authorized in that behalf by the Registrar.

CAUTION.—The applicant must himself sign the application. Any person signing for another, whether requested to do so or not, is liable to a fine of £50. The witness must not sign without having actually seen the applicant write his name, or without hearing the person signing declare that he has read the statement and that the signature is in his own handwriting. Any person making a false declaration is liable to a fine of £20, or to three months' imprisonment.

[See back hereof.

[Back.]

Surname :

Christian name :

Occupation : [Female elector to state “Spinster,” “Married,” or “Widow.”

Full residential address :

Signature of Applicant :

The Particulars within this Space are to be filled in by the Registrar.

(a.) Received (Date) : (d.) Approved (Date) :

(b.) Indexed (Date) : (e.) Transfer notice sent (Date) :

(c.) Checked (Date) : (f.) Acknowledged (Date) :

[Front.]

[Form No. (2).

APPLICATION FOR REGISTRATION BY SEAMAN.

Electoral District of .

I HEREBY apply to have my name entered on the Electoral Roll of the above district, and I declare that the statements made in this application, including those set forth on the back hereof, are true to the best of my knowledge and belief.

(1.) I am not under the age of twenty-one years.

(2.) I am a British subject by birth; or

(3.) I am a British subject by NATURALIZATION [Strike out statement that IN NEW ZEALAND. does not apply.]

(4.) I have resided in New Zealand for twelve months. (A seaman shall be deemed to reside in New Zealand during the time he is engaged in any ship trading exclusively within the territorial waters of New Zealand, or in any ship trading to New Zealand ports at intervals of not more than three months.)

(5.) I have no settled residence in any electoral district; or

(6.) My settled residence is in the Electoral [Strike out statement that District of. does not apply.]

[Note.—A seaman is deemed to have a settled residence in a district if in fact he has in that district a home at which he habitually resides when not engaged in any ship.]

(7.) I have resided in the above district for a period of not less than three months immediately preceding the date of this application.

(8.) My name is on the Electoral Roll for ) [If not already enrolled (9.) My address on that Electoral Roll is strike out these two statements.]

Signature of Applicant :

Signed and declared by the Applicant, before me, this day of 19

Signature of Witness : [Registrar, or Deputy Registrar, or Authorized Agent of Registrar, or Justice, or Postmaster, or an Elector of the District.]

Address of Witness :

NOTE.—If the applicant cannot write, his mark must be witnessed by a Justice, or a Postmaster, or a Registrar, or some person authorized in that behalf by the Registrar.

No. 80]