PVS 1 REGISTER OF ELECTORS Application for inclusion in ...

1 form Version: 08/2015 REGISTER OF ELECTORSA pplication for inclusion in theSupplement to the PostalVotersListby persons with aPhysicalIllness or a PhysicalDisabilityPlease read the notes carefully before completing the A-Particulars of ApplicantName:(block letters)[Please include other details such as Snr., Jnr., other name or an initial if there is anotherperson with the same first name and surname living at the same address.]Address:(block letters)Eircode:Date ofBirth:Declaration and ApplicationI hereby declare that I am unable to go in person to vote at a polling station byreason of a physical illness or a physical disabilityand that I am ordinarily residentat the above address.

2 I hereby apply to have myname entered in thesupplementto the postal ormarkof Applicant:Witness (in case of mark):Date:Daytime/Mobile Phone Number:E-Mail:PVS1 Part B-Medical CertificateThis part must be completed in the case of a first Application and, in the caseof subsequent applications , where required by the registration hereby certify that the above named applicant has a physical illness or a physicaldisability, the nature and extent of which are as follows:_____and for that reason will be unableto go in person to the polling station to illness or physical disability is likely to continue for:_____Signature of RegisteredMedicalPractitioner:Nameof Registered MedicalPractitioner:(block letters)Address:(block letters)Eircode:Date.

3 NOTESTO FORMPVS1 Application for inclusion in the Supplement to the PostalVotersList by persons with a Physical Illness ora Physical purpose of this form is to facilitatevoters who live at home,who arealready on the current REGISTER of ELECTORS but not on the postal voters listandwho, because of a physical illness or physical disability which is likely tocontinue throughout the period of thecurrentregister,wish to be included inthe supplement tothe postal voters there are no restrictions on when the form may be completed and sent tothe registration authority, thelatest date for receiptof an Application by aregistration authority is two days after the date of dissolution of the D il in thecase of a general election and two days after the polling day order is made inthe case of a D il bye-election in order to be considered for that election.

4 Inthe case of a Presidential, European or local election or a Referendum anapplication must be received by the registration authority at least 22 daysbefore polling day (not including Sundays, Good Friday or Public Holidays) inorder to be considered for that election or the Electoral Act 1992, as amended by the Electoral (Amendment) Act1996, an elector with a physical illness or physical disability who isliving athome may apply to his orher local registration authority tobe included in thepostal voterslist.

5 An elector in this category is not eligiblefor entry in thespecial voterslist. An elector whose nameis entered in the postal voterslistmay voteonly by postat an election or a can apply?If you are a person described at 1 above,you may apply for entry in thesupplement to the postal fills out the Application ?The Application form is divided into two parts. The applicant must complete PartA of the form . In the case of a first Application , Part B of the form must becompleted by a do I send the Application form ?

6 Completed Application formsshould be sent or delivered toyour registrationauthority (City, County or City and County Council). happens next?You will be notified by the registration authority of the decision on yourapplication and, if it is refused, you will be given the reasons for the the national postcode system for Ireland and comprises a unique 7-digit postcode which has been allocated to every address in detailsYour contact details are being sought in case the registration authority needs tocontact you to clarify any details of the is an offence to fail to give the registration authority any information requiredfor the purpose of their duties or to knowingly give false ta an Leagain seo den Fhoirm.

7 08/2015CL R NA dTOGHTH IR Iarratas dhaoine ar a bhfuil Tinneas Coirp n M chumas Coirpchun a n-ainm a chur san ireamh san Fhorl onadh a ghabhann leLiosta na bPostv t laitheL igh na n ta go c ramach, le do thoil, sula gcomhl n idh t an A Mionsonra faoin Iarratas irAinm:(bloclitreacha)[Cuir isteach mionsonra eile, le do thoil, amhail M r, Beag, ainm eile n t slitir, m t duine eile ag a bhfuil an t sainm n an sloinne c anna ina ch na n ina c na ag anseoladh c anna.]Seoladh:(bloclitreacha)Eircode:D ta Breithe:Dearbh agus IarratasDearbha m leis seo nach bhfuil m in ann dul gopearsanta chun v ta a chaitheamh ist isi n v ta ochta de bharr tinneas coirp n m chumas coirp a bheith ormagus gobhfuil gn thch na orm ag an seoladh anaim iarratas leis seo m ainm achur san ireamh san fhorl onadh a ghabhann le liosta na bpostv t ni n marc an Iarratas raFinn (i gc s ina n- s idtear marc)D ta:Uimhir theileaf in i rith anlae/Uimhir F in P ca:R omhphost.

8 PVS 1 Cuid B Teastas Docht raN m r an chuid seo a chomhl n i gc s an ch ad iarratais agus, i gc siarratas ina dhiaidh sin, m cheangla onn an t- dar s cl r ch in m leis seo go bhfuil tinneas coirp n m chumas coirp ar an iarratas irthuasainmnithe, agus is mar a leanas cine l agus m id an tinnis n an mh chumaissin: _____agus, ar an bhar sin, n bheidh s /s in ann dul go pearsanta chun v ta achaitheamh sa st isi n v ta ochta: Is d cha go leanfaidh an tinneas coirp n anm chumas coirp ar aghaidh go ceann: _____S ni an Lia-Chleacht raChl raithe:Ainm an Lia-Chleacht raChl raithe:(bloclitreacha)Seoladh:(bloclitre acha)Eircode:D ta.

9 NOTA A GHABHANN LE FOIRM PVS1 Iarratas dhaoinear a bhfuil Tinneas Coirp n M chumas Coirp chun a n-ainma chur san ireamh san Fhorl onadh le Liosta na bPostv t is cusp ir don fhoirm seo an bealach a r iteach do v t laithe a bhfuilc na orthu sa bhaile, a bhfuil a n-ainm ar chl r reatha na dtoghth ir achnach bhfuil a n-ainm i liosta na bpostv t laithe agus mar gheall ar thinneascoirp n m chumas coirp a d igh a leanfaidh le linn thr imhse an chl ir reathaar mian leo a n-ainm a chur san ireamh san fhorl onadh a ghabhann le liostana bpostv t nach bhfuil aon srianta ann i dtaobh cathain a fh adfar an fhoirm achomhl n agus a chur ar ais chuig an dar s cl r ch in.

10 Is at sa d tadeireanach a nglacfaidh dar s cl r ch in le hiarratas n dh l tar is dh tal nscor na D la i gc s olltoghch in agus dh l tar is an t-ord maidir leis anl v ta ochta a dh anamh i gc s corrthoghch in D la le gur f idir an t-iarratasa bhreithni i gcomhair an toghch in sin. I gc s toghch in Uachtar in,toghch in Eorpaigh n toghch in iti la n i gc s Reifrinn, n m r an t-iarratasa bheith faighte ag an dar s cl r ch in 22 l ar a laghad roimh an l v ta ochta (gan Domhna , Aoine an Ch asta n Laethanta Saoire Poibl a ireamh) le gur f idir a bhreithni i gcomhair an toghch in n an reifrinn Acht Toghch in 1992, arna leas leis an Acht Toghch in (Leas )