1 About you 4 Why do you want a proxy vote?
Surname
First name(s) (in full)
Your address (where you are registered to vote)
Postcode
Telephone no (optional)
Email (optional)
Providing an email and telephone number
gives a quick and easy way to contact you
about your application.
2
About your proxy (the person you
have chosen to vote on your behalf)
Full name
Family relationship (if any)
Full address
Postcode
Email or telephone no (optional)
Please explain why you are not able to go to
your polling station on polling day:
3
At which election(s) and referendum(s)
do you want a proxy vote?
I want to vote by proxy at the election(s)
and referendum(s) held on:
D M Y YD M Y Y
Only one person can apply to vote by proxy using this form
Please write in black ink and use BLOCK LETTERS. When you have completed every section
and signed the form yourself, send it to: Electoral Services, Town Hall, 5 Clove Crescent,
London, E14 2BG
P3
Application to vote by proxy at a
particular election or referendum
5 Your date of birth and declaration
Declaration: I have asked the person I have
named as my proxy and conrm that they are
willing and capable to be appointed to vote on
my behalf.
As far as I know, the details on this form are
true and accurate. I understand that to provide
false information on this form is an offence,
punishable on conviction by imprisonment of
up to two years and/or a ne.
Date of birth: Please write your date of birth
in the boxes below using black ink.
D M Y YD M Y Y
Signature: Sign below using black ink,
keeping within the grey border.
6 Date of application
Today’s date
D M Y YD M Y Y
If you are unable to sign this form, please
contact your electoral registration ofce.
