This form is free of charge									Serial No :
	ELECTIONS (REGISTRATION OF ELECTORS) REGULATIONS 2002
	FORM A
	REGISTRATION OF ELECTORS
	PART I								PART III
	To :								For office use only
		Registrar,
		Registration Area
	I apply to have my name entered in the Principal Electoral Roll.
	1	* Elector category :		Ordinary/Absent Voter
	2	Name :
			(Name as in the Identity card/Armed Forces Card/Police Card)
	3	NRIC/Armed Forces/Police No.:
			NRIC No. (Old)			NRIC (New) No.	Armed Forces/Police No.*		Code :
		Applicant							Category
		Husband/Wife							Sex
	4	Address (as in NRIC/Working Address for Armed Forces/Police/Absent Voter)							Race
									Religion
									State
									Parliament
	5	*Sex	Male/Female			6. Tel No.			SA
	7	Race		8. Religion		9. Date of Birth			PD
	10	State			11. Parliament				Locality
	12	SA				13. PD			PART IV
	14	Locality							Date key-in to computer
	15	I declare that -							Name :
		*a)  I am a citizen of Malaysia							Signature :
		*b)  I never registered as an elector at any constituency							Date :
		*c)  I have been registered as an ordinary voter/absent voter in the constituency of
									RART V
	16	I am aware that the penalty for a false statement is imprisonment for a term not exceeding two years or a fine not							Checked by :
		exceeding five thousand ringgit or both such imprisonment and fine in accordance with section 3 of the							Name :
		Election Offences Act 1954 (Act 5).
									Signature :
	Date :					…………….…………………………			Date :
	*delete whichever is not applicable					(Applicant's Signature/Applicant's Thumb Print)
	PART II
	(DECLARATION OF WITNESS)
	( 1)	Signed (or marked) in my presence by the above-named applicant who acknowledge to me that the contents thereof had been read
		by him and I declare that I am a citizen of Malaysia who is not less than 21 years of age.
	NRIC No.(New)				Signature of witness…………………………..
	Witness's Name
	Witness's Address
						Postcode			State
	PART VI
	REGISTRATION OF ELECTORS
	Sir,
	Your application to be registered as an elector has been received. This letter, however, does not guarantee that your name will be entered
	in the principal electoral roll and you are therefore, requested to inspect the draft roll, when it is opened for inspection.
	If, on inspection, you find that your name is not in the said roll, please call at the State Election Office early to enable me to
	carry out further investigation. Please bring this letter along with you.
	Registration Area
	Date :						…………………………………………………..
							Signature of Registrar/Deputy Registrar/Assistant Registrar