EVR No :
Date of Registration
:
Data Entry date
:
Registration Venue
:
:
APPLICATION TO CORRECT/CHANGE OF VOTER DETAILS
Change
Correction
Information Section:
1. You can only register to vote ONCE.
3. All registrations are in person (the person must be present) and completed forms are to be submitted to an FEO
4. Persons who submit false information or attempt multiple registration may be referred to authorities for
prosecution.
5. Place a tick(s) in the box located at the begining of each section e.g. (
Part 1: Personal ........) to indicate the
section(s) or detail(s) that require(s) ammendment(s).
Part 1: Personal Details of Applicant
Surname:
First Name
Other Names:
Maiden Name
Date of Birth:
/
/
Place of Birth
Current Occupation:
Gender:
Mother’s Surname:
Mother’s First Name
Marital Status:
Married
Female
Single
First Name:
Last Name:
Other Names:
Date of Birth (of spouse):
Part 2: Contact Details of Applicant [
]
Mobile (1) :
Home Phone:
Mobile (2):
Email:
Contact Preference:
Email
Male
Work:
Postal
Part 3: Address details of Applicant [
Residential Address: [
]
Postal Address
Town/City
[Please provide details of any disability or polling place requirements]
Special Needs:
Closest Polling Venue:
Alternative Polling Venue:
Polling Venue Code:
Polling Venue Code:
OPS-005
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Part 4: Details of next of kin [Please provide information of a person over 18 years of age]
Relationship to you:
Full Name:
EVR Number:
Mobile:
Email:
Postal Address: [This part is compulsory]
Residential Address:
Town/City
Part 5: Declaration by Applicant
I,
solemnly and sincerely declare that:
1. I am over the age of 18 years;
2. I am a citizen of Fiji
3. The information provided in this form is true and accurate to the best of my knowledge and I am aware that it is an
offence under section136 (a) of the Electoral Decree to provide false statement or declaration to the Fijian Elections
Office or an election official.
Signature of Applicant: [Please see note below before you sign]
Note: Please sign this Application in the presence of a Registration Official.
Date:
For official use only
Registration Official Name:
Registration Official Signature:
Identification produced:
Identification number:
Confirmed Polling Venue:
Polling Venue Code:
www.electionsfiji.gov.fj
Warning- Section 136(a) of the Electoral Decree:
Any person who knowingly and wilfully makes a false statement or declaration in connection with an application for registration as a voter or any other statement or declaration for the purpose of the Electoral Decree 2014 commits an offence
and shall be liable upon conviction to a fine not exceeding $50,000 or to a term of imprisonment not exceeding 10 years, or
to both.
OPS-005
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