Such application shall be in form substantially as follows:
APPLICATION OF PERMANENTLY PHYSICALLY DISABLED PERSON FOR ADMISSION AS AN ELECTOR
To the Town Clerk of the town of .... or to the registrar of voters of the .... Party of the town of .... I hereby apply for admission as an elector:
Dated at ...., Connecticut, this .... day of ...., 20...
.... (Signature of Applicant)
Conn. Gen. Stat. § 9-31b
(1959, P.A. 200, S. 3; 684, S. 4; February, 1965, P.A. 407, S. 4; 1967, P.A. 390, S. 5; 1969, P.A. 198, S. 2; 1971, P.A. 768, S. 11; 871, S. 65; P.A. 73-630, S. 17, 19; P.A. 78-153, S. 8, 32; P.A. 83-391, S. 8, 24; P.A. 84-319, S. 9, 49.)