image/svg+xmlELECTION OFFICIAL MANUAL PART 4: DECLARATION ISSUING OFFICERS
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Declaration Vote P940 envelope
Former surname if changedsince you last enrolled
LIST OFSTREETSCHECK
ELECTOR’SDISTRICT
(Absent, Section 110 and Early Votes)
Declaration Vote
Roll Ref ID
Date of birth
Addressfor whichelector is, orclaims to be,enrolled
Given names
Surname
POSTCODE
I declare that:1.2.3.
I am enrolled at the address shown above.I have not already voted at this election.The information shown above is true and correct and I am entitled to vote.
Electorto sign
ELECTION OFFICIAL to complete
I hereby certify that the above-named elector signed/marked this declaration inmy presence and I have checked the elector’s District from the List of StreetsVictoria for the following vote:(tick box ✓)
Issued at
District
Absent
Marked as Voted
Early
Voting Centre
Making a false statement is an indictable offence (5 years maximum imprisonment or a fine up to 600 penalty units)
Election Officialto sign
Date
EEBCHECK
Admit
Reject
EEB Initials
Date
P940
Signed by Election Official
Elector Sign
ELECTION OFFICE CHECK
On Roll
please use
ELECTOR to complete ( BLOCK LETTERS)
Former surname if changedsince you last enrolled
LIST OFSTREETSCHECK
ELECTOR’SDISTRICT
(Absent, Section 110 and Early Votes)
Declaration Vote
Roll Ref ID
Date of birth
Addressfor whichelector is, orclaims to be,enrolled
Given names
Surname
POSTCODE
I declare that:1.2.3.
I am enrolled at the address shown above.I have not already voted at this election.The information shown above is true and correct and I am entitled to vote.
Electorto sign
ELECTION OFFICIAL to complete
I hereby certify that the above-named elector signed/marked this declaration inmy presence and I have checked the elector’s District from the List of StreetsVictoria for the following vote:(tick box ✓)
Issued at
District
Absent
Marked as Voted
Early
Voting Centre
Making a false statement is an indictable offence (5 years maximum imprisonment or a fine up to 600 penalty units)
Election Officialto sign
Date
EEBCHECK
Admit
Reject
EEB Initials
Date
P940
Signed by Election Official
Elector Sign
ELECTION OFFICE CHECK
On Roll
please use
ELECTOR to complete ( BLOCK LETTERS)