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DECLARATION VOTE
POLLING OFFICIAL TO COMPLETE
OFFICE USE
Division Finderref. or ECL
Cert.ID
To DRO for theDivision of
Issued at
Surname
Given names
Daytimephone
Date of birth
Gender
CURRENT DETAILS
1
Currentpermanentaddress
M
/
/
M
Y
Y
D
D
Are the details you gave above the same as they appear on the electoral roll?
ENROLMENT
2
No
Yes
Go to section below
3
Surname
Given names
Address onelectoral roll
Are you an Australian citizen?
No
Yes
Town ofbirth
Countryof birth
CITIZENSHIP AND IDENTITY
3
EITHER
OR
Australian driver's licence or passport number
Another enrolled person who can confirm your identity
I declare that I am on the Commonwealth electoral roll and I confirmthe identity of this elector.
Surname
Given names
M
/
/
M
Y
Y
D
D
Date of birth
Signature
DECLARATION
4
I declare that I am entitled to vote and have not voted in this election/referendum. I am eligible and claim enrolment for my current permanentaddress, where this is not my enrolled address. The information I have givenon this form is complete and correct.
Your signature or mark
Witnessed by issuing officer signature
M
/
/
M
Y
Y
D
D
Date
NOTE: Giving false or misleading information is a serious offence
OFFICE USE
POLLINGOFFICIAL TOCOMPLETE
If usingECL donot useDivisionFinder
PRE-ISSUECHECK
Division Finder
Current
Enrolled
Issue ballotpaper foraddress onElectoral Roll
If evidenceof identityincompletecontinue toissue ballotpaper
PRE-ISSUECHECK
Voter'ssignature
Issuingofficer'ssignature