Absentee Ballot Request

Name

Title Mr. Mrs. Miss Ms.

First *

Middle

Last *

Suffix Jr Sr II III IV

Contact Information

Primary Email *

Please Confirm Your Email *

Phone * (select country flag first)

Phone Type * Home Work Mobile Other

Previous Name

(Use this option if you want to update your name)

Title Mr. Mrs. Miss Ms.

First

Middle

Last

Suffix Jr Sr II III IV

Alternate Contact Information

 

Alternate Email

Alternate Phone (work phone, cell phone)

Phone Type Home Work Mobile Other

Birth Date

Month * Select 1 2 3 4 5 6 7 8 9 10 11 12

Day * Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year * Select 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

 

Home Address

Where you are registering to vote
Your legal address used for voting purposes

Use Rural Route

Use Address Description

Address 1 * (Cannot be a P.O. Box)

Address Description *

Address 2 (Apt, Suite, Building, Floor, etc.)

City/Town *

County

State * - Select - Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code *

ZIP+4

Voting Region * (Select state to see options)

- Select -

Ballot Mail-to Address

Enter address information ONLY if it is different from your Home Voting Address

Address 1

Address 2 (Apt, Suite, Building, Floor, etc.)

City/Town

County

State/Province/Region

Zip/Postal Code

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