ROCKVILLE                                               2317

or petty officer, other than applicant; if in Merchant Marine, certifying
officer may be a master, first officer, chief engineer or purser; or an am-
bassador, minister, charge d'affaires, counselor to or secretary of a le-
gation, consul general, consul, vice-consul, commercial attache, or con-
sular 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
OFFICE 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 mentally com-

(Name of Voter)

petent to vote in the municipal 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.

Physician                                         Reg. No.

(Address)

(iii) The application for all other absentee voters shall be in the fol-
lowing 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