The Curmudgeon


Friday, June 23, 2006

Form E(V)/1

You are legally obliged to fill in this form. Answer ALL questions. Failure to provide information, or the giving of false information, will result in denial of Chamber services and possible legal action.

Title: Mr Master Mrs Miss (circle as applicable)
Given names:


Class: Elector Citizen Subject (circle as applicable)
Please note: Subjects of the Realm are NOT permitted Chamber services without the consent of their Citizen-Patron. Subjects of the Realm should attach certificate E(V)/SC/17, completed and signed as necessary, to this form before submission.

Date of birth:
Please note: Under-eighteens are NOT permitted Chamber services without the consent of at least one parent, guardian or Citizen-Patron. Under-eighteens should attach certificate E(V)/JC/09, completed and signed as necessary, to this form before submission.

Please list ALL school, college and (if Citizen) university courses:

Please note: Designated war personnel are NOT permitted Chamber services. Conscripts should consult their Psychological Wellbeing Officer about discharge and/or transfer to a Combat Zone.

Previous occupations (including periods of unemployment):

If during the past 2 years you have been unemployed for any period(s) of 3 months or more, please give the name and address of your Encouragement Officer:

Name and address of next of kin:

Have you any savings? YES NO (circle as applicable)

If YES, in what sort of account is the money deposited?
State Bank Private Bank Investment Bank (circle as applicable)

How much is in the account as of the date on this form?
Sixty-two per cent of this amount reverts to the State in payment for Chamber services. For exemptions see leaflet E(V)/F/41.

Are you registered as any of the following?
Disabled Vagrant Unstable Unreliable (circle as applicable)

If you have been an Elector, how did you vote at the last poll for which you were eligible?
Please note: This question is purely for statistical purposes and your answer will not affect your right to Chamber services.

Who referred you to this Chamber?
Self Relative Friend Employer/Citizen-Patron Encouragement Officer Other (please specify):

This is a legal document. Please check your answers before submission. Once your answers have been officially verified, staff will determine the precise extent of your inalienable right to Chamber services, in accordance with the Euthanasia (Voluntary) Act. You will then receive form E(V)/2 which has the legal status of a Will. You should receive form E(V)/2 or a letter within one week of submitting this form. Thank you for your co-operation.

I hereby state that all information given here is true and complete.



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