Request to be Added to the Permanent Absentee Voter Application List

I request to be added to the Permanent Absentee Voter Ballot list for the following community:

City or Township *

Please complete the information below:

Applicant Information

Your Name *

Year of Birth *

Address *

City *

State *

Zip *

Phone Number and Email Address are not required, but are helpful in case your local clerk has questions about your request:

Phone Number

Email Address

Mailing Address (if different from registered address above)

.