Request for Vote by Mail Application 1.1

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We can mail an application to a voter if you, at a minimum, obtain their name, address, and the reason for voting by mail. If you can provide as much of the other information requested, it will help us confirm the correct link to voters in VAN and ensure that the application goes to the right place.

At this point in the calendar, we are only able to provide a hard copy of the application. We can no longer send a pre-filled form or an envelope with the Clerk's address on it. You can assist the voter in obtaining the mailing address for their clerk from the instructions in the Hotline FAQ.

First Name
*

Middle Name (optional)

Last Name *

Voter's Phone Number (Will allow Clerk to contact if application needs changes) *

Voter's Email (Will allow Clerk to contact if application needs changes)

Voter Registration County *

Voter Registration Street Address *

Voter Registration City *

Voter Registration Zip *

Reason for voting by Mail *

65 years of age or older

Disability By checking this box, I affirm that, “I have a sickness or physical condition that prevents me from appearing at the polling

Out of county during early voting and on election day

Expected to give birth within three weeks before or after Election Day

Confined in jail or involuntary civil commitment

Date of birth (if known)

YYYY

Address where BALLOT should be sent if different from voter registration address. This address can only be:

Hospital, Nursing Home, Long-Term Care Facility, Retirement or Assisted Living Center or a Relative

Address Outside the County (voters absent from the county, i.e., college students)

Confined in Jail or Involuntary Civil Commitment

Clear selection

Mailing Address if selected option above (If not known yet, leave blank and voter can supply when they sign application.)

Street or PO Box and Apartment (if needed)

Mailing City

Mailing State

Mailing Zip

If ballot is being mailed to home of relative, what is their relationship (child, parent, etc.)

Date out of county mail can be received. (Current date if now.)

YYYY

Submit

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