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2. Today's Date*
   Today's Date
3. Election Name
   (i.e. General Primary Election)
4. Election Date*
   Election Date
6. First Name*
7. Last Name*
9. What is Your Date of Birth?*
   What is Your Date of Birth?
10. Daytime Contact Phone Number*
12. What is the Address that you want the ballot to be mailed to?
13. Exceptions
    -- Select One --Elderly - I am 65 years of age or olderDisabled - I have a physical disability.UOCAVA - Member of the Military, Spouse or Dependent MOS - Military OverseasOST - Overseas Temporary ResidentMST - Military StatesideOSP - Overseas Permanent Resident (federal offices only)

    If you meet the following criteria, choose one
14. Email For UOCAVA Voters Only
    I would like to receive my ballot by electronic transmission.
16. Mailing Address*
18. Mailing Address Line 2
20. City*
21. State*
22. Zip Code*
24. Is Your Mailing Address the Same as your Physical Address?

    1. Yes
    2. No
26. Physical Address*
28. Physical Address Line 2
30. City*
31. State*
32. Zip Code*
34. Party Affiliation*
    -- Select One --DemocraticRepublicanNon-Partisan
36. 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.
38. Electronic Signature*
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field