Proxy Application Form

APPLICATION TO VOTE BY PROXY
AT A SPECIFIC ELECTION
If you need help filling in this form please contact
Electoral Services helpline on 020 7527 3110
Please write in BLACK INK and BLOCK CAPITALS.
1 Address where you are registered to vote
5
Reason for Application (you must give a
reason why you can not vote in person)
2 About you
6 Your date of birth and signature
Surname:
First Name(s):
Daytime or mobile telephone or email (Optional)
…………………………………………………………
3 How long do you want to vote by proxy?
I have asked the person I have named as my Proxy
and confirm that he/she is willing and able to be
appointed to vote on my behalf.
Date of birth
Please write your date of birth in the boxes below
(e.g. 02 05 1965)
D D M M Y Y Y Y
For elections on
Day Month Year
Please note This application cancels any proxy
voting arrangements you may have made before
4 Name and Address of Appointed Proxy
Declaration
As far as I know the details on this form are true
and accurate. You can be fined for making a false
statement on this form.
Signature
Please enter your usual signature in the box below
using BLACK ink.
Name
…………………………………………..…………
Address
…………………………………………….……………
…………………………………………….……………
………………….……Post Code………….………..…..
Relationship to You (if any)
………………………….…………………..…….
Important – keep signature within the border
If you fail to do this, the application will not be valid.
Todays Date…………/….…..…/……….…

Application to Vote by Proxy
This form is designed to allow for applications for specific elections. If because
of reasons of disability, employment or educational commitments you wish to
make a longer term proxy appointment, please contact the Electoral Services
team.
Please make sure that once you have provided all the necessary details
requested in parts (1) to (5), you include your date of birth and your normal
signature in part (6). This information will be used as a security measure to
ensure that the integrity of the ballot at an election is maintained.
If you are unable to provide a signature because of injury or disability, please
contact the Electoral Services team for further advice.
Before returning the application form, please make sure that you date it. The
form should then be returned by post or by hand to theElectoral Registration
Officer via the details below.
OUR CONTACT DETAILS:
Electoral Services
Town Hall
Upper Street
London N1 2UD
Tel No: 020 7527 3110
Fax No: 020 7527 3289
Email: electoral.services@islington.gov.uk
Website: www.islington.gov.uk