PRINCE GEORGE'S COUNTY BOARD OF…

                                PRINCE GEORGE'S COUNTY BOARD OF ELECTIONS
                               APPLICATION FOR LISTING OF REGISTERED VOTERS
                                              (PRINT ALL INFORMATION EXCEPT SIGNATURE)

MAILING ADDRESS                                         WEB PAGE ADDRESS                                        TELEPHONE NUMBERS
16201 Trade Zone Ave., Suite 108 http://www.co.pg.md.us/Government/AgencyIndex/Elections/costs.asp?h=20&s=&n=80 OFFICE : 301/430-8020
Upper Marlboro, MD 20774                                                                                        TTY: TBA


                               LAST                                   FIRST                                    MI
APPLICANT NAME:
                               NUMBER                      STREET                                 STATE                         ZIP CODE
APPLICANT ADDRESS:
                                              COUNTY                   ELECTION DISTRICT/WARD                       PRECINCT
REGISTERED VOTER IN:
     *I HEREBY APPLY TO PURCHASE A LISTING OF REGISTERED VOTERS OF PRINCE GEORGE'S COUNTY*

                                              TO BE REPRODUCED ON (CHECK ONE)
TAPE [      ]           DISKETTE [ ]                     CD [   ]             LABELS [      ]          PRINTOUT (LISTING) [          ]
                 (No sort or option available)
                                        SORT AND OPTIONS (Circle letter and Check)
                        (Printouts, Labels, CD's, and Diskettes (Check options and complete as necessary)
a.     Active voters [ ]        Inactive voters [ ]        Both [ ]    j.     Alpha by last, voters of one party
                                                                              (Specify party):
b.     Household (Labels Only): One per household        [ ]           k.     District/precinct sequence, voters of one party
                                One per last name        [ ]                  (Specify party):
c.     Municipality: (Please specify town/city)                        l.     Alpha by last name, voters of one party
                                                                              Party :

                                                                              Precincts:
d.     By zip code: [      ]                                           m.     By Legislative district:
                                                                              Specify District: _____________________________________
                                                                              Select sort option:
e.     By district/precinct (Specify)                                  n.     By specific registration dates (Specify start and end dates
                                                                              (MM/DD/YY) and sort option)


f.     Alpha by last name [         ]                                   o.    Alpha by street name (Select additional sort option above)


g.     Alpha by ward [         ] (Municipalities only)                 p.     Voter history (Select up to 3 elections only and please
                                                                              specify):
                                                                              1. ________________________________________________
                                                                              2. ________________________________________________
                                                                              3. ________________________________________________

h.     District/precinct sequence, alpha by last name within           q.     Voters who have registered since ________ election (Specify)
       district and precinct [     ]

i.     Alpha by last name within district/precinct                      r.    By Councilmanic
       (specify precincts)                                                      Specify District:    ____________________________
                                                                                Specify Sort Option: ____________________________
                                                                                ______________________________________________


IS THIS LIST BEING PURCHASED ON BEHALF OF A CORPORATION OR OTHER BUSINESS ENTITY? IF YES,
NAME:______________________________________________________________________________________________
ADDRESS: _________________________________________________________________________________________

INTENDED USE OF LIST: ____________________________________________________________________________
_____________________________________________________________________________________________________

A deposit in the amount indicated on the reverse side of this page (in the form of cash, certified check, personal or
campaign check, or money order) must accompany this application. I, ______________________________________,
                                                                                Applicant's Name - Please Print
agree to pay the balance due, as indicated on the reverse, prior to receipt of the requested output.

PLEASE READ STATEMENT BEFORE SIGNING: Under penalty of perjury, I hereby declare, as
required by Article 33, Section 3-507, Annotated Code of Maryland, that I do not intend to and I will not
use the list of registered voters for which I am applying for purposes of commercial solicitation or for any
other purpose not related to the electoral process, and that I will not knowingly allow the list to be used by
any other person or entity for purposes of commercial solicitation or for any other purpose not related to the
electoral process. I am aware that any person who knowingly allows such a list under his or her control to
be used for commercial solicitation or for any other purpose not related to the electoral process is guilty of a
misdemeanor and is subject to punishment under Article 33, Title 16, Annotated Code of Maryland.

(____)________________________(____)_____________________                            _____________________________________________
Home Telephone Number         Business Telephone Number                                       Signature of Applicant
                                PRINCE GEORGE'S COUNTY BOARD OF ELECTIONS
                                   PURCHASE OF VOTER REGISTRATION LISTS

                                                GENERAL INFORMATION

                                                 SORT OPTIONS
  Voter registration lists may be produced in tape, diskette, CD, printout or label format. If the applicant
  specifies tape, diskette and/or CD, no sorts can be provided. However, the following sort options will be
  provided for printouts and labels.

      By municipality (specify town/city and select sort option)
      By voter history (select up to three elections only - please specify)
      Active voters only, inactive voters only, or both (active and inactive voters)
      Household, one per household or one per last name (labels only)
      All voters, alphabetical by last name
      All voters, precincts in sequence, alphabetical by last name within precinct
      One or more precincts - all voters, alphabetical by last name within precinct
      Voters of one party, alphabetical by last name
      Voters of one party, precincts in sequence, alphabetical by last name within precinct
      One or more precincts - voters of one party, alphabetical by last name within precinct
      By legislative district
      By specific registration dates
      By date of birth
      By street name (alphabetical)

                                The Prince George's County Board Of Elections
                    Has Arrived At The Following Cost Structure For Voter Registration Lists.
     Tapes (Round Reel)                     Diskettes/CD                          Labels                Printouts
  Set up fee - $10.00              Set up fee - $10.00                Set up fee - $10.00      Set up fee - $10.00
  Tape charge - $20.00 per reel    $1.00 per 5,000 records            Plus $.01 per record     Plus $.0050 per record
  (Applicant supplies the tapes)   Disk Charge - $5.00
                                   CD Charge - $5.00

  MAXIMUM: $70.00                  DEPOSIT: $10.00*                   DEPOSIT: $10.00*         DEPOSIT: $10.00*
  DEPOSIT: $20.00*


  A deposit in the amount specified above, in the form of cash, certified, personal or campaign check, or
  money order** made payable to "Prince George's County, Maryland", must accompany each
  application. The applicant agrees to pay the balance due prior to receipt of the requested output.

   *MINIMUM CHARGE
  **PERSONAL CHECK POLICY - ALL RETURNED CHECKS WILL BE ASSESSED A $25.00 FEE
  *** DEPOSITS ARE NON-REFUNDABLE
  ****When picking up your item(s) please bring exact changes (Cash, Check or an Expense
  Distribution Form)

  QUALIFICATIONS: To apply for a voter registration list the applicant must be a registered voter in
  Maryland and must sign a statement, under penalty of perjury, that the list is not intended to be used for
  purposes of commercial solicitation or any other purpose not related to the electoral process. (Article 33,
  Section 3-507, Annotated Code of Maryland and COMAR 33.03.02.03A and 33.03.02.04)

  APPLICATIONS DEADLINE: Before any election, neither the State Administrator nor any Elections
  Director may respond to an application for a voter registration list unless the application was filed on or
  before the registration deadline. Applications received after that date will be returned.
  (COMAR 33.03.02.05B)

  Processing time: Standard 7 to 10 Business days to process you application, that does not include
  weekends and holidays, no exception.

         For Further Information Contact: Barbara Johnson at 301-430-8084 or Susan Kreutter at 301-430-8030
VIN: ____________________________________      Shared: Applications for Request1.doc                   Revised January 24, 2006