ROCKVILLE                                               2375

(Notary Public or other person authorized to administer oaths;
commissioned officer, noncommissioned officer, not below the rank of
sergeant, or petty officer, other than applicant; if in Merchant
Marine, certifying officer may be a master, first officer, chief en-
gineer or purser; or an ambassador, minister, charge d'affaires, coun-
selor to or secretary of legation, consul general, consul, vice-consul,
commercial attache, or consular agent to the United States accredited
to the country where the acknowledgment is made; or a notary public
of the country where the acknowledgment is made; or a judge or
clerk of a court of record of the country where the acknowledgment
is made.)

(ii) Any qualified voter who is unable to vote in person because of
physical disability shall complete the medical certificate required by sub-
section (b) of this Section, which shall be in substantially the following
form and which certificate shall be filed with the board at the same time
this application is returned to the board.

SUPERVISORS OF ELECTIONS OF

CITY OF ROCKVILLE

111 South Perry Street

Rockville, Maryland, 20850

CERTIFICATE OF PHYSICIAN

(THIS CERTIFICATE MUST BE RECEIVED AND FILED AT OUR OF-
FICE NOT LATER THAN TEN(10) DAYS PRIOR TO THE ELECTION)

This is to certify that in the opinion of the undersigned attending

physician........................................who resides at........................................, is

(Name of voter)

mentally competent to vote in the municipal election to be held on..................

and that because of illness or injury the voter is now, or will be pre-
vented from personally voting at said election.

.................................                      Reg. No.

(Physician)

(Address)

(iii) The application for all other absentee voters shall be in the
following form:

(Date)
Board of Supervisors of Elections of the City of Rockville

I, .........................................., hereby apply for a City of Rockville

Absentee Ballot for the Election to be held on..................................................

(Date of Election)

I will not be able to vote in person because................................................,

(State Reason)

My home address is ........................................, Rockville, Montgomery

(No. and Street or RFD)
County, Maryland, and my voting district, to the best of my knowledge,

is.................................