4.—An applicant to be included in the special voters list shall furnish in support of his application a certificate in the prescribed form from a medical practitioner certifying—
(a) the nature and extent of the physical illness or physical disability suffered by such applicant,
(b) an estimate of the duration of such physical illness or physical disability,
(c) that the applicant is of sound mind and understanding and is capable of comprehending the act of voting.
