Vzor 1
SEZNAM VOLIČŮ PRO VOLBY DO EVROPSKÉHO PARLAMENTU
Číslo volebního okrsku ..........
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| Poř. | Jméno, popř. | Příjemní | Rodné | Datum | Místo narození x) | Státní občanství | Místo trvalého pobytu nebo místo | Poznámka |
| číslo | jména | | příjemní x) | narození | | | pobytu na území České republiky, | |
| | | | | | | | popř. místo bydliště mimo území | |
| | | | | | | | České republiky | |
| | | | | +--------------+--------------+------------------+----------------------------------+--------------+
| | | | | | Místo | Stát | | | |
+-------+--------------+--------------+----------------+------------+--------------+--------------+------------------+----------------------------------+--------------+
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+-------+--------------+--------------+----------------+------------+--------------+--------------+------------------+----------------------------------+--------------+
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x) uvede se u voliče, který je zapsán do seznamu pro volby do Evropského parlamentu na základě své žádosti podle § 29 zákona