The application to be subscribed by the voters before receiving a mail ballot shall, in addition to those directions that may be printed, stamped, or written on it by authority of the secretary of state, be in substantially the following form:
STATE OF RHODE ISLAND APPLICATION OF VOTER FOR BALLOT FOR ELECTION ON_________________________________________
I CERTIFY THAT I AM ELIGIBLE FOR A MAIL BALLOT ON THE FOLLOWING BASIS: (CHECK ONE ONLY)
BOX D OATH OF VOTER
I declare under the pains and penalty of perjury that all of the information I have provided on this form is true and correct to the best of my knowledge. I further state that I am not a qualified voter of any other city or town or state and have not claimed and do not intend to claim the right to vote in any other city or town or state. If unable to sign name because of blindness, disability, or inability to read or write, the applicant shall mark the box to indicate the voter cannot sign due to blindness, disability, or inability to read or write, and include the full name, residence address, signature, and optionally the telephone number and e-mail address of the person who provided assistance to the voter.
SIGNATURE IN FULL_________________________________________
Please note: A Power of Attorney signature is not valid in Rhode Island.