Marvin Mandel, Governor                         511

I am not now registered and I will be 21 years old or older on

........................................................................[,]; or

(Date of Election)
I am not now registered and I will be 18 years old or older but less

than 21 years old on........................................................................, and

(Date of Election)

I wish to be registered as.............................................................

(Party or Decline)
I desire that the ballot be sent to me at the following address:

(Sign Name)

(Military rank or other status if
any, or the spouse of)

(Military Rank or other status)

Warning! The Absentee Voting Law provides that anyone who wil-
fully signs any false application or oath, or who wilfully does any
act contrary to the terms and provisions of the Absentee Voting Law
with intent to cast an illegal vote or to aid another in doing so, or
who wilfully violates any of the provisions of that law or who applies
for a ballot under any other name than his own, shall, upon convic-
tion, be subject to a fine of $1,000 or to imprisonment for not more
than two years, or to both, in the discretion of the court.

(2) Any qualified voter who is unable to vote in person because
of physical disability shall complete the medical certificate required
by Section 27-2 of this article, which shall be in substantially the
following form and which certificate shall be filed with the boards at
the same time this application is returned to the boards:

SUPERVISORS OF ELECTIONS OF

(Baltimore City or County)

(Address)

CERTIFICATE OF PHYSICIAN

(THIS CERTIFICATE MUST BE RECEIVED AND FILED AT
OUR OFFICE NOT LATER THAN [TEN (10)] SEVEN (7) DAYS
PRIOR TO THE ELECTION)
This is to certify that in the opinion of the undersigned attending

physician ...................................................... who resides at ......................................................

(name of voter)

is mentally competent to vote in the................................................Election to be

held on ......................................................................................................and that because of

illness or injury the voter is now, or will be prevented from personally
voting at said election.

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

(Physician)

(Address)

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

(Date)