Place

Stamp  

Here

Place

Stamp  

Here

Paid  for  by  America  360  Committee

Michael  Adams,  Treasurer

801  Pennsylvania  Ave  NW,  Suite  610

Washington,  DC  20004

Prsrt  Std    

US  Postage

PAID

SPG

Absentee ApplicationI  am  a  registered  voter  at  the  

address  included  on  this  card.  I  

hereby  request  an  absentee  ballot  

for  the  reason  shown  below.  Please  

mail  my  ballot  to  the  address  

included  on  this  card.

I  will  be  absent  from  my  city  

or  town  on  election  day.

I  have  a  physical  disability  

that  prevents  my  voting  at  

the  polling  place.

I  cannot  vote  at  the  polls  due  

to  my  religious  beliefs.

__________________________________

Full  Name  

__________________________________

Address

______________        ______          ___________

City                    State                  Zip

(            )                    -­                                                  ___/___/_____

Telephone                      Date  of  Birth

__________________________________

Ward/Precinct  (if  known)

____________________________                    _______________

Signature                                                    Date

Massachusetts Absentee Ballot ApplicationNovember 6, 2012 General Election

Absentee ApplicationI  am  a  registered  voter  at  the  

address  included  on  this  card.  I  

hereby  request  an  absentee  ballot  

for  the  reason  shown  below.  Please  

mail  my  ballot  to  the  address  

included  on  this  card.

I  will  be  absent  from  my  city  

or  town  on  election  day.

I  have  a  physical  disability  

that  prevents  my  voting  at  

the  polling  place.

I  cannot  vote  at  the  polls  due  

to  my  religious  beliefs.

__________________________________

Full  Name  

__________________________________

Address

______________        ______          ___________

City                    State                  Zip

(            )                    -­                                                  ___/___/_____

Telephone                      Date  of  Birth

__________________________________

Ward/Precinct  (if  known)

____________________________                    _______________

Signature                                                    Date

Massachusetts Absentee Ballot ApplicationNovember 6, 2012 General Election