Distributable Vote-by-Mail Ballot Application


Name of organization or candidate
distributing Vote-by-Mail applications:
Zip Code:
Statement of distribution plans:
Name to appear on the forms as being provided by:

Choose one:


I will be collecting completed Vote-by-Mail Applications. I understand that I am not to retain any completed Vote-By-Mail Applications for more than 72 hours excluding weekends and state holidays.

I will not be collecting the completed Vote-by-Mail Applications. I will be distributing the applications to voters who are interested in voting by mail ballot for the current election only.


BY SUBMITTING THIS APPLICATION, I DECLARE UNDER PENALTY OF PERJURY THAT I WILL TAKE REASONABLE STEPS TO ENSURE THAT: 1. The person or persons distributing Vote-by-Mail Applications will not refuse to allow the voter to return his/her own application. 2. The Vote-by-Mail Application will not be altered, defaced or changed in any way, other than to add the name of the candidate, committee or organization providing the form, and I agree to use the camera-ready form provided by the Registrar of Voters. 3. If I pre-print Vote-by-Mail Applications with the voter’s name, address, party affiliation and complete affidavit number, I will not use a registered voter tape or index that is more than 30 days old. 4. I have received an information sheet, which contains relevant Vote-by-Mail Application requirements.