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House Name/Apt No.
I hereby apply to be registered in the parliamentary register of the following constituency:
I declare the applicant was born in (if applicable):
Is a commonwealth citizen
Does not possess Bermudian status but was registered as an elector on 1 May 1976
Is not registered in the parliamentary register of any other constituency
Has not applied to be registered as an elector in any other constituency
Is not disqualified for registration as an elector