Application to vote by proxy - Huntingdonshire District Council

Application to vote by proxy at a particular electionOnly one person can apply to vote by proxy using this form. Please write in black ink and useBLOCK LETTERS. When you have completed every section and signed the form yourself, sendit to your electoral registration office. You can get the address at www.aboutmyvote.co.uk1 About you4 Why do you want a proxy vote?SurnamePlease explain why you are not able to go to yourpolling station on election day:First names (in full)Your address (where you are registered to vote)5Your date of birth and declarationPostcodeDaytime telephone or mobile number (optional)E-mail address (optional)Declaration: I have asked the person I have named asmy proxy and confirm that he/she is willing and able tobe appointed to vote on my behalf.As far as I know, the details on this form are true andaccurate. I understand that to provide false informationon this form is an offence, punishable on convictionby imprisonment of up to 2 years and/or a fine.Date of birth: Please write your date of birth‘DD MM YYYY’ in the black boxes below,using black ink.2About your proxyFull nameRelationship to you (if any)Signature: Sign below, keeping within the grey border.Full addressPostcode3At which election do you want a proxy vote?I want to vote by proxy at all election(s) held on:D D M M Y Y Y YIf you are unable to sign this form, please contactyour Electoral Registration Officer.6Date of applicationToday’s dateD D M M Y Y Y Y