Application For Vote By Mail Ballot - Hackensack, Nj
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1
2A
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ote by
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Allot
MILITARY/OVERSEAS VOTER ONLY
Please type or print clearly in ink. All information required unless marked optional.
I request Vote-By-Mail Ballots for all elections in which I am
I hereby apply for a Mail-In Ballot for the:
eligible to vote and I am
(MARK ONLY ONE)
(CHECK ONLY ONE)
1
r A Member of the Uniformed Services or Merchant Marine on active
r General (November)
r Primary
r Municipal
r School
r Fire
duty, or an eligible spouse or dependent.
/
/
______________
r A U.S. Citizen residing outside the U.S. and I intend to return.
r Special
_______________
To be held on
r A U.S. Citizen residing outside the U.S. and I do not intend to return.
(Date)
(Specify)
2
First Name
Suffix (Jr., Sr., III)
Last Name
(Type or Print)
Middle Name or Initial
(Type or Print)
Address at which you are registered to vote
Mail my ballot to
Same Address as Section 3
the following address:
Apt.
Street Address or RD#
Please include
3
4
any
PO Box, RD#,
State/Province,
Municipality
State
Zip
(City/Town)
Zip/Postal Code
& Country
(if outside US)
7
E-Mail Address
Date of Birth
Day Time Phone Number
5
6
(Optional)
(
)
/
/
Signature
T
Please sign your name as it appears in the Poll Book.
oday’s Date
8
9
X
______________________________
/
/
OPTIONAL - ONLY COMPLETE SECTIONS 10 THROUGH 12 IF APPLICABLE
Voter Options to Automatically Receive Ballots in Future Elections
You may choose either option, both options, or none of the options. YOU ARE NOT REQUIRED TO CHOOSE AN OPTION.
If you do not choose any option, you will only be sent the ballot for the election you chose in Section 1.
10
*A
r I wish to receive a Mail-In Ballot for all elections to be held during the REMAINDER OF THIS CALENDAR YEAR.
*B
r I wish to receive a Mail-In Ballot in ALL FUTURE NOVEMBER GENERAL ELECTIONS, until I request otherwise.
*Please Note: Your ballot can only be sent to the mailing address supplied on this application; if your address changes, you must notify the County Clerk in writing.
Assistor
Any person providing assistance to the voter in completing this application must complete this section.
11
Name of Assistor
Signature of Assistor
Date
(Type or Print)
X
/
/
Municipality
Address
Apt.
State
Zip
(City/Town)
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.
I designate
____________________________________________
to be my Authorized Messenger.
Print Name of Authorized Messenger
Address of Messenger
Apt.
Municipality
Zip
Date of Birth
State
(City/Town)
/
/
12
X
_____________________________________________
/
/
Signature of Voter
Date
Authorized Messenger must sign application and show photo ID
OFFICE USE ONLY
STOP
in the presence of the County Clerk or County Clerk designee.
Voter Reg # ____________________________
“I do hereby certify that I will deliver the Mail-In Ballot directly to
Muni Code #_______ Party _______________
the voter and no other person, under penalty of law.”
Signature of Messenger
Ward __________ District ________________
Date
X
/
/
NJ Division of Elections - 08/15
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