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2. PERMANENT ABSENTEE VOTER APPLICATION REQUEST FROM
4. NOTICE
   We will automatically send you an absentee ballot APPLICATION for each election with this request. You will not receive a ballot until you have returned the application for each election. We will not ever automatically send the actual ballot.
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Year of Birth*
    Enter your birth year (xxxx) ONLY
16. Phone Number
17. Email Address
Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field