1188
THE NEW ZEALAND GAZETTE.
[No. 35

signed is his own proper name. Any person making a false declaration is liable to a fine of £20, or to three months' imprisonment.

[See back hereof.]

[Back.]

Particulars to be filled in by Applicant.

{ Surname : .
Full 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.]
[Reg. 2 (1).]

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 have attained the age of twenty-one years.

(2) I am a British subject by birth ; }
or
(3) I am a British subject by NATURAL- { [Strike out statement
IZATION IN NEW ZEALAND. } that does not apply.]

(4) I have resided in New Zealand for one year. (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 } [Strike out statement
electoral district ; or } that does not apply.]
(6) My settled residence is in the { Electoral District of . }

[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) [Strike out if any settled residence is stated.] The ship in which I am engaged usually calls at the following port comprised, or partly comprised, in the above electoral district : [Name of port.]

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

Signature of Applicant : .

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

Signature of Witness : .
Address of Witness : .

NOTE.—A witness must be :—
(a) A Registrar or Deputy Registrar : or
(b) An elector of the district in which the applicant or declarant resides, or some person authorized in that behalf by the Registrar of that district ; or
(c) The Chief Electoral Officer, or Deputy Chief Electoral Officer, or any other officer in the service of the Government authorized in that behalf by the Chief Electoral Officer ; or
(d) A Justice or Postmaster.

CAUTION.—The applicant must himself sign the application by name or mark. 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 signature or without actually hearing the person signing declare that he has read the statements and that the signature is in his own handwriting, and that the name so signed is his own proper name. Any person making a false declaration is liable to a fine of £20, or to three months' imprisonment.

[See back hereof.]

[Back.]

Particulars to be filled in by Applicant.

{ Surname : .
Full Christian name : .
Occupation : .
Name of ship engaged on : .
Settled residence (if any) : .
}

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) : .

—

NOTICE OF TRANSFER. [Form No. 3.]
[Reg. 2 (2).]

No. on former roll :
PLEASE remove from your Electoral Roll the name of—
Name in full [Surname, full Christian name] :
Occupation on former roll :
Address on former roll :
as he was enrolled in this district on this day of , 19 .

Registrar for the Electoral District of . . . . . . . .

—

[Form No. 4.]
[Reg. 2 (3).]

NOTIFICATION OF DEATH TO BE GIVEN BY REGISTRAR OF BIRTHS AND DEATHS.

SURNAME of deceased :
Full Christian name :
Usual residence :
Occupation : [In the case of female insert “Spinster,” “Married,” or “Widow.”].
Age :
Date and place of death :
If married, state name of widow or widower :
The above particulars are supplied in terms of section 42 of the Electoral Act, 1927.

Registrar of Births and Deaths at . . . . . . . .

—

[Form No. 5.]
[Reg. 2 (4).]

NOTIFICATION BY REGISTRAR OF MARRIAGES OF INTENDED MARRIAGE OF ADULT WOMAN.

NAME of bride : [Surname, full Christian name.]
Name of bridegroom : [Surname, full Christian name.]
Date of giving notice of marriage :
Full residential address (after marriage) :
Particulars as to present registration of bride—
(a) Name of Electoral District :
(b) Full name and description as given on roll :
(c) Address on roll :
The above particulars are supplied in terms of section 43 of the Electoral Act, 1927.

Registrar of Marriages at . . . . . . . . . . . .

—

Consecutive No. of ballot-paper : [Form No. 6.]
[Reg. 3 (4).]

APPLICATION FOR BALLOT-PAPER BY PERSON VOTING AS AN ABSENT VOTER.

I HEREBY make application to vote as an Absent Voter under section 139 of the Electoral Act, 1927, and the regulations made thereunder, and I declare that I am the person registered on the electoral roll of the Electoral District of † as—
[Surname, full Christian name.]
[Full residential address, as appearing on roll.]
[Occupation.]
I also further declare that—
(a) I am entitled to vote for the electoral district for which I am registered.
(b) I am not qualified to be enrolled as an elector of any other electoral district.

Usual Signature of Applicant : .

Signed and declared before me this day of , 19.
. . . . . . . . . . . ., Deputy Returning Officer.
[or Postmaster.]*

Booth No. . . . . . . .Polling-place.

Name of electoral district in { . . . . . . . . . . . . . . . . . . . . . . . .
which application is made : }

• Declaration may be signed before Postmaster in case only of a by-election.
  † The correct electoral district must be stated, otherwise the vote will be disallowed.