(a) On the back of each registration form (or on a separate form if an alternate electronic registration system is used), there shall be printed a ten-year voting record form substantially as follows:

VOTING RECORDName of Voter

YEAR

PARTY

General

Primary

Other

Election

Election

Election

Ballot No. or

Ballot No. or

Ballot No. or

Ballot

Ballot

Ballot

Application

Application

Application

Number

Number

Number

1971

______________

1972

______________

Continued for remainder of ten (10) years

______________
(b) The year dates printed in the first column shall be changed with each year’s printing of the form.