| 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. |