Application to Amend Voter Information

Check only one(Required)

Add applicant’s name to list

Correct applicant’s information on list

Delete applicant’s or family member’s name from list

Reason for deletion

Moved away

Deceased

Name of Applicant(Required)

First Name of Applicant Middle Name of Applicant Last Name of Applicant

Date of Birth (Applicant)(Required)

Qualifying address on voting day

Is the qualifying address on voting day commercial property?(Required)

Yes

Address(Required)

Street Number and Name Roll Number Postal Code

If house apartment, indicate floor level – (e.g. basement, 1st floor, etc.)

At the qualifying address, applicant is:(Required)

Owner

Tenant

Other

Spouse

S.S.P. (Same Sex Partner)

Unqualified (deleted name only)

Previous qualifying address (if applicable)

Address

Street Number and Name Roll Number Postal Code

If house apartment, indicate floor level – (e.g. basement, 1st floor, etc.)

At the previous address, applicant was:

Owner

Tenant

Other

Spouse

S.S.P. (Same Sex Partner)

Unqualified (deleted name only)

Current Mailing Address

Address(Required)

Street Number and Name Post Office Box City Province Postal Code

School Support

Applicant is Roman Catholic (includes Greek and Ukrainian Catholics)

Applicant has French Education Rights

Applicant is not Roman Catholic and does not have French language rights

Applicant wishes to be an elector for the following school board

English-Public (anyone can support English-public)

English-Separate (must be Roman Catholic)

French-Public (must have French Language Educaton Rights)

French-Separate (must be Roman Catholic and have French Language Education Rights)

View Acceptable Forms of Proof of Identity

Please upload proof of identity – must have a picture of applicant and current address (e.g. driver's license, passport)

Max. file size: 300 MB.

I, the undersigned, hereby declare that I am a Canadian citizen, that I have attained the age of eighteen (18) on or before Voting Day, and that on Voting Day, I am entitled to be an elector in accordance with the facts or information submitted on this form, and that I understand the effect thereof. I hereby apply to have my name included or amendments made on the Voters’ List in accordance with such facts or information.

By clicking “I Agree” you certify that the information you provide is true and accurate. It is a punishable offence under the laws of Canada to misrepresent one’s identity or to knowingly provide false or misleading information and City of Brockville reserves the right to share information with law enforcement authorities where suspicious activity is detected, fraud is suspected or there is reason to believe an offence may have been committed.

Do you agree with the statement above?(Required)

Agree

Disagree

Name of Applicant(Required)

First Name of Applicant Last Name of Applicant

Email address(Required)

Primary Phone Number(Required)

Date form submitted(Required)

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Application to Amend Voter Information

Application to Amend Voter’s List

Qualifying address on voting day

Previous qualifying address (if applicable)

Current Mailing Address

View Acceptable Forms of Proof of Identity