APPLICATION FOR OFFICIAL ABSENTEE BALLOT
NOTE: You may submit your application by mail, by facsimile transmission, or in person. A disabled or illiterate voter may receive assistance.
County or Municipality:
P L E A S E P R I N T (FAILURE TO FILL OUT THIS FORM COMPLETELY WILL DELAY YOUR APPLICATIOW
I Name as registered:
Date of Birth:
Address as registered:
Mailing address on registration record:
( C I w
Date of Primary, Election, or Runoff:
If requesting ballot for primary, designate ballot type:
PLEASE CHECK THE APPROPRIATE BOX: (circle one of the codes below)
ABSENTEE VOTING: Please see reverse side for description of codes and circle one of the codes below:
E OP D CG EO RH PS MST MOS OSP OST NR(ByMailOnly)*
ADVANCE VOTING (In Person Only): Monday - Friday of the week immediately preceding the election; not required to provide a reason.
MANNER IN WHICH ABSENTEE BALLOT IS PROVIDED:
Ballot to be mailed to voter.
Ballot issued and voted in registrar's office.
Ballot to be delivered to voter in hospital (at Registrar's discretion).
Mail ballot to my temporary out-of-county address (or alternate address in the case of a physically disabled voter).
Address to mail ballot to:
MILITARYIPHYSICAL DISABLED1 75 YEARS OR OLDER VOTERS:
You may choose to submit one application and receive a ballot for the Primary, Primary Runoff, Election, and Election Runoff if you meet the
A member of the Armed Forces or Merchant Marines of the United States or a spouse or dependant living outside the county or municipality in
which the election is held or a civilian permanently or temporarily residing overseas; or
A voter age 75 or older, or
A separate application must be made for the Presidential Preference Primary if you are
A voter with a physical disability. 1 z
By checking this box you are stating: I meet the above criteria and I choose to receive all absentee ballots as allowe