APRIL 27.] THE NEW ZEALAND GAZETTE. 1189

Consecutive No. of voting-paper : [Form No. 7.
Consecutive No. of declaration : [Reg. 6.

DECLARATION BY PERSON APPLYING TO VOTE WHOSE NAME
IS RULED OUT ON CERTIFIED COPY OF THE ROLL.

I, [Full name of elector], do hereby declare as follows :—
(1) That I am the person whose name appears on the certified copy of the Electoral Roll as , and whose name so appearing is ruled out thereon.
(2) That I am legally qualified to be registered as an elector for the aforesaid district.
(3) That I am not registered on any other electoral roll, and that I am not aware of any circumstances by reason of which my name ought to be so ruled out.
(4) That I have not already voted at this election.

Signature of Elector : .
Full residential address : .
Occupation : .

Declared before me day of , 19 .
, Deputy Returning Officer.
Polling-place.

—

Consecutive No. of voting-paper : [Form No. 8.
Consecutive No. of declaration : [Reg. 6.

DECLARATION BY PERSON APPLYING TO VOTE WHO, HAVING APPLIED FOR REGISTRATION, HAS NOT BEEN REGISTERED.

I, [Full name of elector], do hereby declare as follows :—
(1) That I duly made application within the time prescribed by law for registration as an elector of the Electoral District, and was informed by the Registrar of Electors that I had been so registered.
(2) That I am legally qualified to be registered as an elector for the aforesaid district.
(3) That I am not registered on any other electoral roll, and that I am not aware of any circumstances by reason of which I ought not to be registered as an elector of the aforesaid district.
(4) That I have not already voted at this election.

Signature of Elector : .
Full residential address : .
Occupation : .

Declared before me this day of , 19 .
. . . . . . . . . , Deputy Returning Officer.
. . . . . . . . . , Polling-place.

—

[Form No. 9.
[Reg. 7 (4).

Consecutive No. :

APPLICATION FOR A POSTAL VOTE-CERTIFICATE AND POSTAL BALLOT-PAPER.

To the Returning Officer for the Electoral District of .
I, [Full name], of [Address as shown on roll], [Occupation or description as shown on roll], hereby apply for a postal vote-certificate and a postal ballot-paper.

I declare that—
(1) I am a registered elector of the Electoral District of .
(2) The ground on which I apply to vote by post is—
(a) That I will, on polling-day, be absent from New Zealand.
(b) That I will not, throughout the hours of polling on polling-day, be within five miles by the nearest practicable route of any polling-place.
(c) That I will, throughout the hours of polling on polling-day, be travelling under conditions which will preclude me from attending at any polling-place to vote.
(d) That I am ill (or infirm), and, by reason of such illness [or infirmity], will be precluded from attending at any polling-place to vote.
(e) That I will, by approaching [or recent] maternity, be precluded from attending at any polling-place to vote.

(f) That I am a lighthouse-keeper [or member of a lighthouse-keeper’s staff] [or am the wife of a lighthouse-keeper], [or the wife of a member of a lighthouse-keeper’s staff], and will be precluded from attending at any polling-place to vote.

NOTE.—The elector is to strike out any of the above grounds which do not apply to his or her particular case.

I request that a postal vote-certificate and a postal ballot-paper be forwarded to me at the following address : .
Dated this day of , 19 .

Signature of Elector : .

Signed and declared by the elector in my presence: [Signature of authorized witness.]
Designation of witness :
Address of witness :

[Form No. 10.
[Reg. 7 (9).

POSTAL BALLOT-PAPER.

Consecutive No. .

Electoral District of .

The elector is to write the name of the candidate for whom he wishes to vote on the dotted line hereunder.

For instructions see back of postal vote-certificate issued with this ballot-paper.

[To be entered here and also on the top left hand corner of the front of ballot-paper.]

Number on roll [To be entered here only.]

[Stamp across the perforation so that part of the stamp shall appear on both the counterfoil and the ballot-paper.]

[Official mark here.]

[Form No. 11.
[Reg. 7 (10).

POSTAL VOTE-CERTIFICATE.

I HEREBY certify that [Full name], of [Address], [Occupation or description], is entitled to vote by post at the election to be held on the day of , 19 , for the electoral district of .

Dated this day of , 19 .
. . . . . . . . . , Returning Officer.
. . . . . . . . .

[Elector to sign here.]

Signed by the elector in my presence—[Witness to sign here.]
Designation of witness :
Address of witness :

Dated this day of , 19 .

F. D. THOMSON,
Clerk of the Executive Council.

By Authority: W. A. G. SKINNER, Government Printer, Wellington.

Price 6d.]