Application For Vote by Mail Ballot Please type or print clearly in ink. All information required unless marked optional.
I hereby apply for a Mail-In Ballot for:
MILITARY/OVERSEAS VOTER ONLY
I request Vote-By-Mail Ballots for all elections in which I am eligible to vote and I am (CHECK ONLY ONE)
(CHECK ONLY ONE)
r ALL FUTURE ELECTIONS, until I request otherwise in writing. Or for ONLY ONE of the following: r General (November)
1 r Primary (June) r Municipal r School r Fire r Special _______________ (Specify)
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To be held on
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(MM / DD / YYYY)
r A Member of the Uniformed Services or Merchant Marine on active duty, or an eligible spouse or dependent. r A U.S. Citizen residing outside the U.S. and I intend to return. r A U.S. Citizen residing outside the U.S. and I do not intend to return. r A U.S. Citizen residing outside the U.S. and I have never lived in the U.S.
PLEASE NOTE: Your ballot can only be sent to the mailing address supplied on this application. If your mailing address changes, you must notify the County Clerk in writing.
2
Last Name (Type or Print)
First Name (Type or Print)
Address at which you are registered to vote:
3 5
4
Municipality (City/Town)
State
Date of Birth (MM / DD / YYYY)
Day Time Phone Number
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6 (
Suffix (Jr., Sr., III)
Mail my ballot to the following address: r Same Address as Section 3
Apt.
Street Address or RD#
Middle Name or Initial
Zip
Please include any PO Box, RD#, State/Province, Zip/Postal Code & Country (if outside US)
E-Mail Address
7
)
PLEASE NOTE: This contact information will be used to contact you concerning the acceptance or rejection of your ballot and how you may cure a defect.
8
Signature: I affirm that I am the person
who is applying for this ballot and I live at the address designated in box 3 of this form.
X _____________________ 9
Today’s Date (MM / DD / YYYY)
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OPTIONAL - ONLY COMPLETE SECTIONS 10 OR 11 IF APPLICABLE
Assistor: Any person providing assistance to the voter in completing this application must complete this section.
10
Name of Assistor (Type or Print)
Date (MM / DD / YYYY)
Signature of Assistor
X
Address
Municipality (City/Town)
Apt.
State
Zip
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Authorized Messenger: Any voter may apply for a Mail-In Ballot by Authorized Messenger. Messenger shall be a family
member or a registered voter of this County. No Authorized Messenger can (1) be a Candidate in the election for which the voter is requesting a Mail-In Ballot or (2) serve as messenger for more than THREE qualified voters per election, except that an authorized messenger or bearer may serve as such for up to five qualified voters in an election if those voters are immediate family members residing in the same household as the messenger or bearer.
I designate ____________________________________________ to be my Authorized Messenger. Address of Messenger
11 Signature of Voter X
Print Name of Authorized Messenger
Apt.
Municipality (City/Town)
Date of Birth (MM / DD / YYYY)
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Date (MM / DD / YYYY)
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Messenger must sign application and show photo ID STOP Authorized in the presence of the County Clerk or County Clerk designee.
OFFICE USE ONLY
“I do hereby certify that I will deliver the Mail-In Ballot directly to the voter and no other person, under penalty of law.” Signature of Messenger Date (MM / DD / YYYY)
NJ Division of Elections - 02/28/21
Zip
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X
State
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Voter Reg # ____________________________ Muni Code #_______ Party _______________ Ward __________ District ________________