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APPLICATION FOR ABSENTEE BALLOT…
Tags: absentee ballot, address street, date of birth, election day, elector, mail ballot, municipality, observance, occupation, physical disability, pollin, post office, religious holiday, residential address, signature, street address, zip code,Pages: 1
Language: english
Created: Wed Sep 29 16:17:18 2004
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APPLICATION FOR ABSENTEE BALLOT
_____________________________________________ Mail ballot to:
PLEASE PRINT NAME AS REGISTERED
_____________________________________________ ____________________________________
STREET ADDRESS STREET ADDRESS
_____________________________________________ ____________________________________
RESIDENTIAL ADDRESS POST OFFICE & ZIP
_________________________________________
POST OFFICE & ZIP CODE
________________________________________ ___________________
OCCUPATION DATE OF BIRTH
***********************************************************************************************
( )Complete Section A ( ) Illness or Physical Disability
( )1 ( )2 ( )3 Complete Section B
***********************************************************************************
Section A
(1) expect to be absent from my municipality on the day of the coming primary or election because of duties, occupation or
business;
(2) observance of religious holiday;
(3) county employee who cannot vote due to duties on election day.
________________________________________ __________________________
Signature of Elector Date
***********************************************************************************
Section B - Illness or Physical disability
I expect to be unable to attend my proper polling place on the day of the coming primary or election because of illness or physical disability,
the nature of which appears below:
____________________________________________________________________________
Insert illness or disability here
________________________________________ _________________
Signature of elector Date
(IF UNABLE TO SIGN COMPLETE LAST SECTION BELOW)
____________________________________________________________________________________
Name of Physician Phone Number
____________________________________________________________________________________
Office Address
THE FOLLOWING IS TO BE COMPLETED IF APPLICANT IS UNABLE TO SIGN
BECAUSE OF ILLNESS OR PHYSICAL DISABILITY.
I hereby state that I am unable to sign my application for absentee ballot without assistance because I am unable to write by
reason of my illness or physical disability. I have made, or received assistance in making, my mark in lieu of my signature.
____________________ ______________________________________________
Date Signature of Witness
____________________ ______________________________________________
My Mark Address of Witness
RETURN APPLICATION TO: CHESTER COUNTY VOTER SERVICES, 601 WESTTOWN RD., SUITE 150,
P.O. BOX 2747, WEST CHESTER, PA 19380-0990
FIRST TIME VOTERS TO CHESTER COUNTY MUST SUBMIT A COPY OF PHOTO I.D. WITH ABSENTEE BALLOT APPLICATION
9/29/2004