Section 7

The principal enactment is hereby amended by the addition immediately after the Fourth Schedule to such enactment of the following new Schedule:—

“FIFTH SCHEDULE

CERTIFICATE OF ELIGIBILITY TO VOTE ISSUED TO A PERSON SUBJ ECT TO A DISABILITY

IN TERMS OF THE PARLIAMENTARY ELECTIONS ACT, NO. 1 OF 1981

(SECTION 40 (2) (C))

PART I

DECLARATION BY THE APPLICANT/VOTER

Full Name : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Address : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Occupation : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date of Birth : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NIC/Driving Licence /Passport No. : . . . . . . . . . . . . . . . . . . . . . .

I, . . . . . . . . . . . . . . . . . . . . . . of . . . . . . . . . . . . . . . . . . . . . being a voter registered in the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . District, being subject to a disability, declare that the above particulars are true and accurate and do hereby apply for the issue of a Certificate of

Addition of the

Fifth Schedule to the principal enactment.

Amendment of section 76 of the principal enactment.

Eligibility entitling me to vote at the forthcoming . . . . . . . . . . . . . .

. . . . . . . . (Name of Election) as a person subject to a disability, as provided for by law.

Date : . . . . . . . . . . . .

Name of Voter : . . . . . . . . . . . . . . . . . . .

Signature of Voter : . . . . . . . . . . . . . . . .

CERTIFICATE OF GRAMA NILADHARI

I certify that the information given above is correct and that the following information relating to the application of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(Name of

Applicant/Voter) is correct according to the records maintained by me.

Name : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No. on the voters list : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Province : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

District : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Electoral Division : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other relevant information : . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date : . . . . . . . . . .

Signature of Grama Niladhari : . . . . . . . .

Name of Grama Niladhari : . . . . . . . . . . .

Division : . . . . . . . . . . . . . . . . . . . . . . . .

Seal : . . . . . . . . . . . . . . . . . . . . . . . . . . .

PART II

CERTIFICATE OF THE GOVERNMENT MEDICAL OFFICER

I have personally examined . . . . . . . . . . . . . . . . . . . . . . . . . . . . .of

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . who has applied to be entitled to vote as a person subject to a disability, at the forthcoming

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name of Election)

and do hereby certify that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(Name of Voter/Applicant) is entitled/not entitled to vote as a person subject to a disability, as provided for by law.

Date : . . . . . . . . . .

Name of Government

Medical Officer: . . . . . . . . . . . . . . . .

Signature of Government

Medical Officer: . . . . . . . . . . . . . . . .

Seal: . . . . . . . . . . . . . . . . . . . . . . . . . .”.

Elections (Special Provisions)