Sections
4, 63, 64
SCHEDULE
FORMS
DECLARATION
BY RETURNING OFFICER, DEPUTY RETURNING OFFICER,
POLL
CLERKS, SCRUTINEERS AND OTHER OFFICERS:
I,
A.B. (Insert full residential address and occupation or description),
solemnly and sincerely declare that I will well and truly serve in the
office of:
Returning Officer
Deputy Returning Officer
Poll Clerk
Interpreter
Scrutineer for C.D., a candidate; at the poll for the
Constituency or Representatives of the Individual
Voters and that I will not do anything forbidden by section 94 of the
Electoral Act 1963.
AND
I make this solemn declaration conscientiously believing the same to be
true and by virtue of the Oaths,
Affidavits and Declarations Act 1963.
Declared
at
..
.
this
day of
..
..
19
.....
before me.
E.F.
Chief Electoral Officer
Returning Officer
Deputy Returning Officer
(Occupation or description of a) person authorised to take a
statutory declaration by section 21 of the Oaths, Affidavits and
Declarations Act 1963.
Delete whichever do not apply.
Section 94 of the Electoral Act 1963 is to be printed on the back
of this form and must be read by or to the declarant.
Section
12
FORM 1A:
To
the Registrar of electors and voters for Western Samoa.
I
of (village claimed, full residential address, and
occupation or description) hereby claim to have
my name entered in the electoral roll for
(Territorial Constituency) of Western Samoa; and I declare
that the answers to the following questions are true and correct
in every particular:
1.
Are you a citizen of Western Samoa?
...
2.
Have you attained the age of 21 years?
.
3.
Are you an undischarged bankrupt?
..
4.
Have you been convicted in Western Samoa or in American Samoa of
an offence punishable by death or
by imprisonment for a term of 2 years or upwards or have you been
convicted in Western Samoa or
reported by the Supreme Court in its report on a trial of an election
petition to have been proved of
any practice declared to be a corrupt practice by the Electoral Act 1963?
5.
If so, have you:
(a)
Received a free pardon?
(b)
Undergone the sentence or punishment to which you were adjudged
for the offence?
6.
Are you of sound mind and not subject to an order of medical
custody under the Mental Health
Ordinance 1961?
7.
What is (or was) the full name of your father?
.
8.
If he is dead, when and where did he die?
9.
What is the date of your birth?
...
10.
What is your fathers village of origin?
.
11.
What are your grandfathres villages of origin?
12.
Do you hold a Matai tittle?
13.
If so, what the details?
Title
..
Village
..
14.
If you do not hold a Matai title does or did any of your
grandparents or your parents or your spouse hold
Matai
title?
15.
If so, supply particulars:
Relationship (eg.
father etc)
...
Title
...
Village
16.
Does or did any of your brothers or sisters hold a Matai title
otherwise then through his or her spouse?
17.
If so, supply particulars:
Name of
brother/sister
...
Title
..
Village:
..
...
18.
What is the full name of your father? .
...
19.
What is the full name of your mother?
..
20.
Are you rendering service to a village?
..
21.
If so, what village?
.
22.
What is the nature of the service and who can confirm it?
SIGN
HERE:
.
Signature
of Witness:
Residential
Address of Witness:
..
Qualification of Witness:
..
Section 21
FORM 2
To
the Registrar of electors and voters for Western Samoa I, (insert full
names, full residential address and occupation or description) hereby
claim to have my name entered on the individual voters roll for
Western Samoa:
A.
That my answers to the following questions are true and
incorrect:
1.
Are you a citizen of Western Samoa under the Citizenship Act
1972?
2.
Have you attained the age of 21 years?
3.
Are you an undischarged bankrupt?
4.
Have you been convicted in Western Samoa or in American Samoa of
an offence punishable by death or by imprisonment for a term of 2 years
or upwards or have you been convicted in Western Samoa of any practice
declared to be a corrupt practice by the Electoral Act 1963?
5.
If so, have you:
(a)
Received a free pardon?
(b)
Undergone the sentence or punishment to which you were adjudged
for the offence?
6.
Are you of sound mind and not subject to an order of medical
custody under the Mental Health Ordinance 1961?
7.
Was your name entered on the European electoral roll on the 30th
day of November 1963?
8.
What is (or was) the full name of your father?
9.
If he is dead, when and where did he die?
10.
Was your fathers name entered on the European electoral roll
on the 30th day of November 1963?
11.
If not and if he died before the 30th day of November
1963, would he if alive on that day have qualified to have his name
entered on the European electoral roll on that day?
12.
Were you unborn or under the age of 21 years on the 30th
day of November 1963?
13.
Did you acquire your citizenship of Western Samoa by:
(a)
Naturalisation?
(b)
Birth?
14.
If the latter:
(a)
Is your father, if alive, a citizen of Western Samoa?
(b)
Would your father if alive at the date of the commencement of the
Citizenship of Western Samoa Ordinance 1959 on the 8th day of
September 1959 have automatically qualified to be a citizen of Western
Samoa by virtue of any provision of that Ordinance?
15.
Have you taken the oath of allegiance in the manner and form
provided by section 12 of the Citizenship Act 1972?
B.
That I do not hold a Matai title and am not exercising any
customary right or privilege in regard to customary land.
C.
That I am not married to a person holding such a title or
exercising any such right or privilege.
SIGN
HERE:
.
Signature
of Witness:
Residential
Address of Witness:
..
Qualification of Witness:
..
Section 35 (1)
FORM 3
ELECTORAL ROLL FOR TERRITORIAL CONSTITUENCY
|
ROLL
OF PERSONS ENTITLED TO VOTE AS ELECTORS OF THE
TERRITORIAL
CONSTITUENCY OF
|
|
Number on
Roll
|
Title(s) or
Surname
|
Taulealea or
Christian Name(s)
|
Sub-Village
or
Pitonuu
|
Village or
Nuu
|
Occupation or
Description
|
|
|
Registrar
Section 35 (2)
FORM 4
INDIVIDUAL VOTERS ROLL
|
ROLL
OF PERSONS ENTITLED TO VOTE FOR REPRESENTATIVES
OF
THE INDIVIDUAL VOTERS
|
|
Number of Roll
|
Surname
|
Christian Names
|
Residence
|
Occupation or
Description
|
|
|
Registrar
Section 48(1)
FORM 5
To
the Chief Electoral Officer for the Constituency
.
.
WE, the undersigned registered electors of the
Constituency, registered individual voters, hereby nominate
..
.. (Name), of (Residence and
occupation), a registered elector of the
..
Constituency, a registered
individual voters, with his (or her) consent, as a candidate at the
election of a member of Parliament for the
.
Constituency, Individual Voters the poll for which is appointed for
Saturday the
... Day of
Dated
at
.
.. this
.
.. day of
.19
(Signatures
and full names, residences, and occupations of 2 or more electors
nominating).
I,
(Name), being qualified to be a candidate and to be elected a member of
Parliament in terms both of Part II of the Electoral Act 1963 and of any
other enactment, hereby consent to the above nomination.
My
name will fit on the ballot paper; or
As
my name is too long to fit on the ballot paper, I wish my given names to
be shown on the ballot paper as
. (Complete the second alternative, unless the Chief Electoral Officer
agrees both that the candidates name will fit on the ballot paper and
that the second alternative is the alternative to be deleted).
The
name of my political party is
.
Or
I
am an independent candidate.
(Signature,
residence, and occupation of person nominated)
Delete
words that do not apply.
Section 52(1)
FORM 6
NOTICE OF WITHDRAWAL OF NOMINATION
To
the Chief Electoral Officer for Western Samoa.
I
(Insert full names) hereby give notice that I withdraw my nomination as
a candidate at the election of:
Representative(s) of the
constituency
Representatives of the Individual Voters the holding of which is
appointed for the
day of
. 19
. And for which I was nominated on the
. Day of
19
Signature
of Candidate: ..
..
Received
at the hour of:
on the
day of
..
19
.
Signature of Chief Electoral Officer:
.
Delete
words that do not apply
Section 56(1)
FORM 7
VOTE HERE
|
FAAOSO,
Pale
HUMAN RIGHT PROTECTION
|
|
|
FALEFA,
Sola
SAMOA NATIONAL DEVELOPMENT
|
|
|
SASALU,
Tolu
SAMOA LIBERAL
|
|
|
TUITUI,
Tolu
INDEPENDENT
|
|
DIRECTIONS
(Read Carefully before Voting)
1.
Vote for only one candidate.
2.
Vote by putting a tick in the circle immediately after the name
of the candidate you choose.
3.
After voting, fold
the ballot paper so that its contents cannot be seen and place it in the
ballot box.
4.
If you spoil this ballot paper, return it to the officer who
issued it and apply for another.
5.
You must not take this ballot paper out of the polling booth.
Section 56(5)
FORM 8
COUNTERFOIL OF BALLOT PAPER
Consecutive No.
(To
be entered here and also on the top right hand corner of the back of the
voting paper).
Designation
of Roll:
No.
on Roll:
(to
be entered here only)
(Stamp
across the perforation so that the number
]
Official
of
the polling booth shall appear on both the
]
Booth
counterfoil
and the voting paper).
]
Stamp
Initials
of Presiding Officer
________________
Section 80
FORM 9
DECLARATION OF RESULT OF POLL
Territorial Constituency of
(or Individual Voters)
I HEREBY
declare the result of the poll taken on the
.. day of
19
. For the election of a member(s) of
Parliament for the Territorial Constituency of (or for Individual
voters) to be as follows:
Candidates
Votes Received
C.D.
..
E.F.
..
G.H.
..
I.J.
..
K.L.
..
Total
number of valid votes
..
Number
of votes rejected as informal
.
..
I
therefore declare the said C.D. to be elected
..
DATED
at
. this
day of
19
A.B.
CHIEF
ELECTORAL OFFICER