FORM A | (r. 13(1), 13A(2)) |
APPLICATION FOR REGISTRATION AS A VOTER |
To the Registration Officer ............................................................................................... |
Constituency ...................................... | County .............................................................. |
Ward .................................................... | Registration centre ........................................... |
Surname ............................................... | Other names ...................................................... |
Identity Card No./Kenyan passport No: ..................................................................... |
Date of birth: .......................................... | Sex .................................................... |
Residential address: ........................................................................ |
Contact Telephone: ......................................................................... |
Postal address: ................................................................................. |
Email: ................................................................................................. |
Disability (if any) : ............................................................................ |
I, the above named applicant, hereby apply to be registered in the Principal Register of Voters in accordance to the Constitution and the Elections Act. |
DECLARATION |
I ............................................................................ , declare that at the date of this application: |
| (i) I am qualified to be, and not disqualified from being, registered as a voter under the law in respect of the classes of election for which I now apply for registration. |
| (ii) I am in possession of a national identity card or Kenyan passport with the number indicated in this application. |
| (iii) The particulars entered on this form or submitted to the Commission (which I have entered, read or have had read to me) are true to the best of my knowledge. |
Dated: ......................................................................... 20 ................................................... |
Signature or Thumbprint of Applicant ............................................................................... |
Witnessed by: ..................................................................................................................... |
Registration Officer/Assistant Registration Officer |
Official stamp. |