VOTING INFORMATION
: Republic of Palau
Office of the Election Commission
P.O. Box 826
Koror, Republic of Palau 96940
Tel: (680) 488-1554 / 4543
Fax: (680) 488-3327
Email: Palauelect@palaunet.com
Please email, call or mail in your request to Palau Election commission. Or email Kerngel at jlehna_kanai@yahoo.com for the pdf. version of these applications.
Revised April, 2007 Affidavit No. _______________
AFFIDAVIT FOR APPLICATION
TO REGISTER TO VOTE
) REPUBLIC OF PALAU
) SS STATE OF _______________________
) HAMLET OF _____________________
Directions: This affidavit is divided into three sections. All applicants must complete Section 1. Only applicants registering for the first time must complete Section 2, and only applicants transferring or re-registering must complete Section 3. Review and complete all required questions on both sides of this affidavit. If a question is not applicable, mark N/A. Your signature on this affidavit attests to the fact that you have answered all questions truthfully under oath.
Prohibitions and Penalties: All citizens should be aware that, pursuant to Republic of Palau law, whoever knowingly gives false information as to his/her name, address or period of residence in the voting state for the purpose of establishing his/her eligibility to register to vote, or conspires with another person for the purpose of encouraging his/her false registration to vote or illegal voting, or pays or offers to pay or accepts payment either for registration to vote or for voting in any election or referendum shall upon conviction thereof, be fined not less than $2,000.00 nor more than $10,000 or shall be imprisoned not more than five years, or both. 23 PNC § 110(a).
SECTION 1: ALL APPLICANTS
(1) My full name is __________________________________________________________________. _________
(LAST) (FIRST) (MIDDLE) SEX
(2) I am also known as ________________________________________________________________
(3) I was born at ___________________________ on the _____ day of ______________, in the year ____________.
(4) My age is ________. My Social Security Number is _______________________________.
(5) My current address is ______________________________________, and my telephone number is __________________________.
(6) My occupation is ______________________________ at ____________________________ State . If you are a student, print the name of the institution you are attending ___________________________________________.
(7) Are you a citizen of the Republic? Yes _____ No _____.
(8) Were you naturalized as a citizen of the Republic? Yes _____ No _____. If yes, provide the day, month, and year on which you were naturalized ______________________. Provide proof of naturalization.
(9) Are you currently in jail serving a sentence for a felony? Yes _____ No _____.
(10) Have you been judged mentally incompetent by a court? Yes _____ No _____.
SECTION 2: APPLICANTS REGISTERING TO VOTE FOR THE FIRST TIME
In order to establish residency in a particular State or hamlet, you must have been physically present in that State or hamlet on a reasonably continuous basis within a 30 day period (or the state's minimum residency period if greater than 30 days) with the intent to establish your permanent home in such State or hamlet. You need not currently live in such State or hamlet in order to be a resident there if your intent to establish your permanent home in that State or hamlet has not changed. First time registrant must provide documents to proof of Palau citizenship.
( "Reasonably continuous basis" means at least 25 days out of a period of 30 consecutive days with an interruption of no more than 48 consecutive hours within the 30 day period.)
Your answers to the following questions will allow the Election Commission to ascertain the State, and hamlet if applicable, in which you are a resident for voting purposes.
(1) I currently physically reside at ____________________ State in ____________________ Hamlet.
(2) I wish to register to vote as a resident of ____________________ State in ____________________ Hamlet.
(3) Have you ever lived in the hamlet and state in which you seek to register to vote for at least a period of 30 days?
Yes _____ No _____. If yes, how many days/months/years did you live in that hamlet and state and provide the approximate dates. ____________________________________________________________________________
(4) If you live in the State and hamlet in which you seek to register to vote, is this the place that you consider your permanent home? Yes _____ No _____.
If you have not physically resided, within the last 30 days, at the State and hamlet in which you seek to register to vote, provide answers to the following questions. If you have so resided there, skip down to applicant’s signature.
(5) Do you still consider that the State and hamlet in which you seek to register as your permanent home?
Yes _____ No _____. If no, provide the State and hamlet that you do consider your permanent home. ____________________ State in ____________________ Hamlet.
(6) I am typically physically present in the State or hamlet in which I seek to register to vote for ___________________ days/months out of a year.
(7) Do you maintain a home in the State or hamlet in which you seek to register to vote? Yes _____ No _____
Do you maintain a home in any other State or hamlet? Yes _____ No _____ . If yes, in what State and hamlet? ____________________ State in ____________________ Hamlet.
(8) Do you or your family own property in the State or hamlet in which you seek to register to vote?
Yes _____ No _____ Do you or your family own property in any other State or hamlet? Yes _____ No _____
If yes, in what State and hamlet? ____________________ State in ____________________ Hamlet.
(9) Do you have any family members who physically reside in the State or hamlet in which you seek to register to vote? Yes _____ No _____ If yes, what family members reside there? ________________________________________
(10) (a) Do you conduct any business in the State or hamlet in which you seek to register to vote?
Yes _____. No _____.
(b) Are you involved in any of the social, political, cultural, governmental, traditional, or religious affairs of the State or hamlet or any organizations or institutions operating within the State or hamlet in which you seek to register to vote? Yes _____. No _____.
(c) Do you have any other connection to the State or hamlet in which you seek to register to vote?
Yes _____ No _____.
(11) If you answered yes to any of the questions in (10), please provide details here. ______________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
SECTION 3: APPLICANTS TRANSFERRING OR RE-REGISTERING TO VOTE
(1) I was last registered to vote as a resident of ____________________ State in ____________________ Hamlet.
(2) I wish to register to vote as a resident of ____________________ State in ____________________ Hamlet.
(3) I currently physically reside at ____________________ State in ____________________ Hamlet. I have physically resided at this location on a reasonably continuous basis for __________ days/months/years immediately preceding this date on which I now offer to register.
(4) Have you lived in the State and hamlet in which you wish to register to vote for at least 25 days within the past 30 day period, with an interruption of no more than 48 consecutive hours within the 30 day period?
Yes _____ No _____.
(5) Do you intend to establish your permanent home in the State and hamlet in which you seek to register to vote?
Yes _____ No _____. If no, provide the State and hamlet that you do consider your permanent home? ____________________ State in ____________________ Hamlet.
I solemnly swear/affirm that the foregoing statements are true.
_____________________________________________
Signature of Applicant Date
FOR OFFICIAL USE ONLY
This is to certify that the Affidavit numbered __________________ has been accepted by the Election Commission in support of the application to register to vote of the applicant, ___________________________________________________
(LAST) (FIRST) (MIDDLE)
The applicant is registered to vote in national elections.
The applicant is also registered to vote in state elections as a resident of ____________________ State in ____________________ Hamlet.
___________________________________________ __________________________________________
Print Name and Title of Official Administering Oath
Signature of Official Date
To: Republic of Palau
Office of the Election Commission
P.O. Box 826
Koror, Republic of Palau 96940
Tel: (680) 488-1554 / 4543
Fax: (680) 488-3327
I, _______________________________, as a Citizen of the Republic of Palau , would
like to request a Registration form so that I may re-register to vote for the upcoming 2008
Primary/General Election. Please send a Registration form to my current address below:
Full Name: _______________________________
Mailing Address: ________________________
Phone (optional): __________________________
Sincerely,
__________________________ _____________________
(Signature) (Date)
**Note: Registration forms must be submitted 60 days prior to the
Primary Election, dated for September 23, 2008.