Who can use this form?
You can use this form to enrol for federal, state and local
government elections in Queensland if you are:
unable to sign your name due to a physical incapacity
18 years or older, and
an Australian citizen, or a British subject who was on a
Commonwealth roll on 25 January 1984.
You can enrol at 16 years but cannot vote until you are 18.
You may get someone else to complete this enrolment form and
sign it on your behalf.
Within three weeks of receiving your enrolment form the AEC will
conrm your enrolment. We may seek further information from you
and conrm your enrolment using any of the contact details you
provide.
Is it compulsory to enrol and vote?
Yes, it is compulsory for all eligible Australian citizens over 18 years
to enrol and vote.
Do you need to provide a medical certificate?
Yes, please have a registered medical practitioner complete and
sign the medical certicate on this form before your application is
returned to the AEC.
Do you have to attend a polling place to vote?
No. You can register as a general postal voter at Question 6 and
you will be sent ballot papers as soon as practicable after the
declaration of nominations for federal, state and local government
elections, or the issue of writs or authorisation for a referendum.
When you receive your ballot papers, you may ask someone else to
help you complete them and then return them to the AEC.
Note: If you choose to vote in person at a polling booth, you can
request assistance in marking your ballot paper.
Help in other languages
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1300 720 146 Russian
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1300 720 147 Serbian
Italiano 1300 720 138 Italian Espańol 1300 720 148 Spanish
1300 720 134 Khmer Türkçe 1300 720 149 Turkish
1300 720 468 Korean
1300 720 152 Vietnamese
1300 720 139 Macedonian Other languages 1300 720 153
1300 720 142 Mandarin
If you are deaf, or have a hearing or
speech impairment
Contact the AEC through the National Relay Service (NRS):
TTY – 133 677 then ask for 13 23 26
Speak and Listen – 1300 555 727 then ask for 13 23 26
Internet relay – connect to the NRS then ask for 13 23 26
Who has access to your enrolment information?
The Commonwealth of Australia
The Australian Electoral Commission (AEC) is authorised under the
Commonwealth Electoral Act 1918 (CEA) to collect and verify the
information you have been asked to complete on this form. The
information provided will assist the AEC to maintain electoral rolls.
The AEC may disclose electoral information to persons or
organisations in accordance with the CEA. This may include:
access to the publicly available electoral roll (containing
names and addresses) which may be inspected at
electoral ofces
state and territory electoral authorities
Members of Parliament, Senators, registered political
parties, and candidates for the House of Representatives
approved medical research and public health
screening programs
any agencies, persons or organisations prescribed in the
Electoral and Referendum Regulation 2016.
For more information on privacy, visit www.privacy.gov.au
The State of Queensland
Electoral Commission Queensland provides electoral information
to organisations authorised under the Queensland Electoral
Act 1992.
For more information
Australian Electoral Commission
www.aec.gov.au or 13 23 26
Electoral Commission Queensland
www.ecq.qld.gov.au or 1300 881 665
Returning your form
Post Australian Electoral Commission
Reply paid 9867
BRISBANE QLD 4001
(No stamp is needed if posted in Australia)
Fax 02 6293 7607
Upload Upload your scanned signed form at
www.aec.gov.au/return
In person
To any AEC ofce
Enrol to vote or update your details
for persons who are unable to sign their name due to
physical incapacity in Queensland
ER022GHw_QLD_0318 © Commonwealth of Australia 2018
Applicant’s date of birth
(dd/mm/yyyy)
2
Gender
ER022GHw_QLD_0318 (page 1 of 2)
© Commonwealth of Australia 2018
5
Applicant’s citizenship
status
To enrol the applicant must
be an Australian citizen, or a
British subject who was on the
Commonwealth electoral roll
on 25 January 1984
Name on citizenship
certificate
Name on 25 January 1984
Australian citizen by birth
I have become an Australian citizen
British subject who was enrolled on 25 January 1984
or
or
Town
of birth
Country of birth
Country of birth
State or territory
Citizenship certificate number
Enrol to vote or update your details
for persons who are unable to sign their name due to
physical incapacity in Queensland
3
Applicant’s current
residential address
Clearly identify this address.
A locality name or mail service
number is not enough
Postcode
State
QLD
Current postal address
Leave blank if the same as
residential address
Postcode
State
If notifying a change of
address
Previous residential address
Postcode
State
4
Email address
Mobile
Applicant’s phone numbers
Daytime
( )
6
Does the applicant wish
to register as a general
postal voter?
No
Postal voting papers will be sent to the postal address given at Question 3Yes
Applicant’s current name
1
Mr
Mrs
Miss Ms
Other
Family name
Given name(s)
Previous given name(s)
Previous family name
If notifying a
change of name
Use a 8 where appropriate.
Use black or blue pen and
BLOCK LETTERS
I2
Office use only –
Date received
NINNotation ACK
CATS
H
Signature Title
Date / /
Approved
Not approved
Instructions
ER022GHw_QLD_0318 (page 2 of 2)
I am a registered medical practitioner and consider that the person named at Question 1
on this form is physically incapable of signing his/her name or making his/her mark.
Medical practitioner’s signature
/ /
-
Returning this form – see information page for instructions
Medical practitioner’s details – Please use BLOCK LETTERS
Full name
Provider number
Phone number
Address
Medical Certificate
Commonwealth Electoral Act 1918 – s98(3)
Postcode
State
( )
Important The following Medical Certificate must be completed by a registered medical practitioner before this form is lodged
The applicant is eligible to enrol at the residential address at Question 3
The applicant is eligible to enrol for federal, state and local government
elections in Queensland
The information given on this form is true and complete, and
I understand that giving false or misleading information is a serious offence.
Declaration
Name and address
(BLOCK LETTERS)
Signature of person who completed this form on behalf of
the applicant in accordance with the applicant’s directions
/ /
-
8
7
Evidence of the
applicant’s identity
Confirm the applicant’s
identity using one of these
three options
Australian driver’s licence
Australian passport
or
or
Number
Number
State or territory
Name and address (BLOCK LETTERS)
Signature
/ /
-
Have a person who is on the Commonwealth
electoral roll confirm the applicant’s identity
I am on the Commonwealth electoral roll, and
I confirm the identity of the applicant.
Date of birth (dd/mm/yyyy)
Please print and sign your form
before returning it to the AEC
Print
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