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2. Permanent Absentee Application Request Form
   Please complete the form below in order to be placed on the permanent absentee voter list. This list will automatically send you an absentee ballot application for each election. The application must be filled out each election cycle in order to receive an absentee ballot.
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Date of Birth*
    Date of Birth
    Please enter your date of birth in MM/DD/YYYY format.
14. Phone Number
15. Email
17. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
19. Electronic Signature
Leave This Blank:


21. Submit

* indicates a required field