APPLICATION TO VOTE BY MAIL
200
E. Race
If you need to vote by mail, and meet one of the
criteria below, fill out this application and return to us by mail or fax no
later than the 7th day before the election.
Name:
_________________________________________________ Check the Election you wish
to vote in:
Street Address: _______________________________________
□
General Election
________________________________________________________
□
Democrat Primary
City/State/Zip: ________________________________________
□
Republican Primary
SSN:
__________________________________________________
Please Mail Ballot To: _________________________________
________________________________________________________
Assistance signatures:
(Required if voter cannot sign, or if assistance is given.)
______________________________________________________________________________________
Signature of Person Assisting Address Date
Check the reason that you are
requesting to vote by mail:
Age 65 or older
Hospitalized, ill or disabled
Caretaker
On the permanently disabled list (must
have Dr’s certificate)
Full Time Student
Juror in State or Federal Court
Observance of Religious Holiday
Will be outside
entire election time.
Resident of Nursing Home outside
Candidate in the Election
Serving as an Election Official
Truck Driver (must have copy of CDL)
I hereby declare that:
·
I wish to vote by mail
·
I am a registered voter in
·
The following signature or mark on this
application is mine
·
I reside at the address listed on this
application
·
I have not previously voted in this
election, nor will I attempt to vote at my polling place on election day
·
I am aware that I can be convicted of a
felony for giving false information on this application or attempting to vote
in an election in which I am not entitled to.
Signature
of Voter Date