Such application shall be in form substantially as follows:

APPLICATION OF PERMANENTLY PHYSICALLY DISABLED PERSON FOR ADMISSION AS AN ELECTOR

To the Town Clerk of the town of .... or to the registrar of voters of the .... Party of the town of .... I hereby apply for admission as an elector:

(1) My name is .... (last name) (first name) (initial).

(2) My bona fide residence is .... (street and number), but I am presently residing at .... (street, number and town if different from residence above).

(3) I am a permanently physically disabled person and my permanent physical disability prevents me and will continue to prevent me from appearing in person at your office.

(4) I am a United States Citizen who has attained the age of eighteen and my electoral privileges are not forfeited by reason of conviction of any disfranchising crime.

Dated at ...., Connecticut, this .... day of ...., 20...

.... (Signature of Applicant)

(1959, P.A. 200, S. 3; 684, S. 4; February, 1965, P.A. 407, S. 4; 1967, P.A. 390, S. 5; 1969, P.A. 198, S. 2; 1971, P.A. 768, S. 11; 871, S. 65; P.A. 73-630, S. 17, 19; P.A. 78-153, S. 8, 32; P.A. 83-391, S. 8, 24; P.A. 84-319, S. 9, 49.)

History: 1965 act deleted section of form for continuous residence in Connecticut; 1967 act deleted date of marriage and birthplace of husband and whether husband alien or native born in reference to married women, added provision to include maiden name and deleted provision for occupation, effective January 1, 1968; 1969 act changed title of application by deleting “for special session” and adding “of permanently physically disabled person” and added “or to the registrar of voters of the ... Party of the town of ....” to the address line; 1971 acts added provision in form for recital of incapacity to prevent applicant from appearing in person at office of town clerk and registrars of voters as well as session held by board, substituted penalty of false statement for penalty of perjury; P.A. 73-630 substituted “my bona fide residence is” for “I reside at”; P.A. 78-153 removed section where marital status to be checked, also section where married woman to indicate name of husband and maiden name, effective January 1, 1979; P.A. 83-391 deleted reference to board for admission of electors; P.A. 84-319 amended section to provide uniformity in statutes pertaining to on-location admission sessions for handicapped persons, students and patients at hospitals and nursing homes; (Revisor's note: In 2001 the reference in this section to the date “19..” was changed editorially by the Revisors to “20..” to reflect the new millennium).