Fill - Free fillable FOR OFFICE USE ONLY *This application must be PDF form

SB-F-1

APPLICATION FOR REGISTRATION AND

SPECIAL BALLOT (Section 86)

Personal information on this form is collected under the authority of the Elections Act, 1991, and the Access to Information and Protection of Privacy Act,

2015. Inquiries regarding this collection should be directed to the Office of the Chief Electoral Officer’s ATIPP Coordinator at (1-877) 729-7987.

ELECTORAL

DISTRICT #

ELECTORAL DISTRICT

NAME

POLLING

DIVISION #

Please complete the following section only if the Special Ballot delivery address differs from mailing address listed above.

ELECTOR INFORMATION

Current Home Address

_______ _________________________________________ __________ ______________________________________________________

Number Street Apt/Unit Building Name (if applicable)

________________________________________ __________________

City/Town Postal Code

Contact Information

Home Phone: ____________________ Cell Phone: ____________________ Alternate Phone: ____________________ E-Mail: _________________________________

Last Name

First Name

Gender

M F X

Date of Birth: ________ /________ /________

yyyy mm dd

I, the undersigned, declare that: I will be at least 18 years old on ordinary polling day; my ordinary residence for voting purposes is as

stated in the “current home address” portion above; I am a Canadian citizen; and, I am not disqualified from voting for any reason.

SIGNATURE OF ELECTOR DATE

OFFICE USE ONLY (Ballot Tracking)

 In-house voting (ballot received)  Ballot mailed  Other: ______________________________

 Elector has taken ballot with him/her  Ballot completed at PCH or Hospital ____________________________________

DECLARATION

Identification Verified:  Type of Identification Provided: _____________________________________________________________________

Elector Added to the Voters List:  Elector’s Information Changed on Voters List:  Elector Information Verified: 

Mailing Address (if different than home address)

_______ _________________________________________ __________ ________________________________________

Number Street Apt/Unit City/Town

_______________ _______________ ________________________ ____________________

PO Box Site Rural Route Postal Code

ELECTOR ID #

__ __ __ - __ __ __

Mailing Address for Delivery of Special Ballot

_______ _____________________________________________ ______ __________ _________________________ __________________

Number Street Apt/Unit Building Name City/Town

__________ ________________________ _______________ _______________ ____________________ ____________________

Province Country PO Box Site Rural Route Postal Code

Contact Information for Delivery Address (phone number and/or email address): ___________________________________________________________________

FOR OFFICE USE ONLY

SIGNATURE OF SPECIAL BALLOT OFFICER DATE

*This application must be accompanied by ID (see back for details)

SB-F-1

APPLICATION FOR REGISTRATION AND

SPECIAL BALLOT (Section 86)

Personal information on this form is collected under the authority of the Elections Act, 1991, and the Access to Information and Protection of Privacy Act,

2015. Inquiries regarding this collection should be directed to the Office of the Chief Electoral Officer’s ATIPP Coordinator at (1-877) 729-7987.

Elections Newfoundland and Labrador requires all Special Ballot applicants to provide proof of their name and current

address. Acceptable ID includes the following options:

1) One piece of ID that shows both your name and current address. For example, your driver’s licence.

2) Two pieces of ID which, together, show your name and current address. At least one must have your current address.

We accept e-statements and e-invoices. You may bring a printed copy or show them on a mobile device. For example:

 health card

 Canadian passport

 birth certificate

 certificate of Canadian citizenship

 citizenship card

 social insurance number card

 old age security card

 hospital card

 label on a prescription container

 identity bracelet issued by a hospital or

long-term care facility

 blood donor card

 credit/debit card

 student identity card

 public transportation card

 library card

 utility bill or cell phone bill

 bank statement

 personal cheque

 government cheque/cheque stub or

pension plan statement

 residential lease or sub-lease

 mortgage contract or statement

 income tax assessment

 property tax assessment or evaluation

 vehicle ownership, insurance certificate,

policy or statement

 letter of confirmation of residence, letter

of stay, admission form or statement of

benefits from one of the following

designated establishments:

o student residence

o seniors' residence

o long-term care facility

3) If you cannot present ID that shows your name and address, you have two options:

 someone who knows you can attest to your identity and current address. This person, known as a Guarantor, must

show proof of their own identity and address, but does not have to be from or live in the same district as you.

However, they can only attest for one person. The Guarantor will have to complete Elections NL’s “Guarantor’s

Form” (SB-F-10).

 complete an affidavit, attesting to your identity in the absence of any other form of ID. Elections NL’s form, called

the “Affidavit for Voting by Special Ballot” (SB-F-12) must be signed by an official, such as a Judge, Barrister, Justice

of the Peace or Commissioner for Oaths.

Important information about ID:

 Your name and current address must be printed on the ID. They cannot be added by hand.

 Expired ID is acceptable, as long as it has your name and current address.

 The list above is not an exhaustive list. If you have questions about the types of acceptable identification for Special

Ballot voting, contact your Elections Newfoundland and Labrador toll-free at 1-877-729-7987.

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Fillable FOR OFFICE USE ONLY *This application must be

Fill Online, Printable, Fillable, Blank FOR OFFICE USE ONLY *This application must be Form

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