FORM P-12

APPLICATION FOR REGISTRATION AND SPECIAL BALLOT (A.S.B)

(Section 86)

If you need more copies of this form, please photocopy it.

OFFICE USE ONLY

Polling Division Number Electoral District Electoral District Code

TO BE COMPLETED BY ELECTOR

Street Address of Ordinary Residence Special Ballot Mailing Address

Number Street Address

Number Street Address

Building Name

Apt. Building Name Apt.

City, Town or Community Postal Code

City, Town or Community Postal Code

Province

Country Province Country

Family Name Given Names (s) Sex

M F

Telephone Numbers

Home – Telephone # ___________________________

Fax ___________________________

Business- Telephone # ____________________

Fax ____________________

Date of Birth _____/_____/_____

Year Month Day

DECLARATION

I, the undersigned, declare that: (Please √ each line)

______ I will be at least 18 years old on ordinary polling day;

______ I am a Canadian citizen;

______ My ordinary residence for voting purposes is as stated

in the “Street Address” above;

______ I am not disqualified from voting for any reason.

_____________________________________ ______________________________________

SIGNATURE OF ELECTOR DATE

NOTE: Attach a copy of an official document showing your name, address and signature, such as a driver’s license or

a combination of two documents providing the same information, as explained in the instructions.

OFFICE USE ONLY

_____________________________________________ ____________________________________________

Signature of Authorized Election Official Date

House of Assembly

Newfoundland and Labrador

APPLICATION

FOR

SPECIAL BALLOT

Printed under the Authority

of

The Chief Electoral Officer

Province of Newfoundland and Labrador

Tel: (709) 729-0712 Fax: (709) 729-0679

www.gov.nl.ca/elections

1-877-729-7987

(toll free – all areas)

INSTRUCTIONS

Electors who have reason to believe that they will

have difficulty voting on the days set for the

Advance Poll or Ordinary Poll may complete this

application for Special Ballot.

The Completed Application must be returned by the

deadline that will be publicly advertised to the

District Returning Office or The Office of the Chief

Electoral Officer, 39 Hallett Crescent, O’Leary

Industrial Park, St. John’s, Newfoundland and

Labrador, Canada, A1B 4C4.

Proof of identification must accompany the

Application. This may consist of a copy of an

official document bearing the elector’s name, address

and signature such as a valid driver’s license.

Alternatively, copies of two documents may be

provided, one bearing the elector’s name and

signature such as a social security card and another

bearing the elector’s name and residence address

such as a utility bill.

All applications received in the District Returning

Office or The Office of the Chief Electoral Officer

by the deadline will be processed. If the application

is approved, the applicant’s name will be

appropriately entered on the voter’s list and a Special

Ballot Kit will be sent by mail to the applicant.

Applicants may make other arrangements to pick-up

the Special Ballot Kit in person at the Office of the

Chief Electoral Officer.

The Special Ballot Kit will enable the elector to write

in the name of the Candidate or Political party or

both on a blank Special Ballot form. This Special

Ballot must be returned, in a series of envelopes

designed to provide voting secrecy, to the District

Returning Office or The Office of the Chief Electoral

Officer by the deadline that will be publicly

advertised.

It is the responsibility of the elector to make

application in a timely fashion and to meet the

deadlines established. Once an Application for a

Special Ballot is approved and a Special Ballot Kit is

distributed, the elector shall not vote in an Advance

Poll or at an Ordinary Poll in the Election.

For further information or assistance, contact

a Special Ballot Officer at (709) 729-0712 or

1-877-729-7987 (toll free – all areas).