7/17/2019 Vote by Mail Ballot - Passaic County (English)
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*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.
2Last Name (Type or Print) Sufx (Jr., Sr., III)First Name (Type or Print)
Middle Name or Initial
3
Address at which you are registered to vote
Apt.
Municipality (City/Town) State Zip
5 6
1
Date of Birth Day Time Phone Number
r General (November) r Primary r Municipal r School r Fire
r Special _______________ To be held on ___ ___ ________
I hereby apply for a Mail-In Ballot for the: (CHECK ONLY ONE)
8 SignaturePlease sign your name as it appears in the Poll Book.
X ______________________________ 9Today’s Date
10 r I wish to receive a Mail-In Ballot for all elections to be held during the REMAINDER OF THIS CALENDAR YEAR
r I wish to receive a Mail-In Ballot in ALL FUTURE NOVEMBER GENERAL ELECTIONS, until I request otherwise
Voter Options to Automatically Receive Ballots in Future ElectionsYou 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.
*A*B
Assistor Any person providing assistance to the voter in completing this application must complete this section.
11 Address Apt. Municipality (City/Town) State Zip
12
Authorized Messenger
Name of Assistor (Type or Print) DateSignature of Assistor
Any voter may apply for a Mail-In Ballot by Authorized Messenger. Messenger shall be a family member or a registered voter of th
County. No Authorized Messenger can (1) be a Candidate in the election for which the voter is requesting a Mail-In Ballot or (2) serv
as messenger for more than THREE qualied voters per election.
I designate ____________________________________________ to be my Authorized Messenger.
Signature of Voter
X
Authorized Messenger must sign application and show photo ID
in the presence of the County Clerk or County Clerk designee.
X _____________________________________________
Please type or print clearly in ink. All information required unless marked optional.
/ /
/ /
/ /
/ /
/ /
(Specify) (Date)
Print Name of Authorized Messenger
Date
OFFICE USE ONLY
Voter Reg # ____________________________
Muni Code #_______ Party _______________
Ward __________ District ________________
( ) 7E-Mail Address (Optional)
Mail my ballot to
the following address:
4Please include
any
PO Box, RD#,
State/Province,
Zip/Postal Code
& Country
(if outside US)
Same Address as Section
DateSignature of Messenger
X / /
Address of Messenger Apt. Municipality (City/Town) State Zip
“I do hereby certify that I will deliver the Mail-In Ballot directly to
the voter and no other person, under penalty of law.”
STOP
Date of Birth
/ /
Street Address or RD#
I request Vote-By-Mail Ballots for all elections in which I am
eligible to vote and I am (MARK ONLY ONE)
MILITARY/OVERSEAS VOTER ONLY
r A Member of the Uniformed Services or Merchant Marine on active
duty, or an eligible spouse or dependent.
r A U.S. Citizen residing outside the U.S. and I intend to return.
r A U.S. Citizen residing outside the U.S. and I do not intend to retur
APPLICATION FOR VOTE BY MAIL BALLOT
OPTIONAL - ONLY COMPLETE SECTIONS 10 THROUGH 12 IF APPLICABLE
NJ Division of Elections - 08/15
7/17/2019 Vote by Mail Ballot - Passaic County (English)
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APPLICATION FOR VOTE BY MAIL BALLOT
PLACE
POSTAGEHERE
BEFORE
M AILING
Name
Street Address
City, State, Zip Code
_________________________________
_________________________________
_________________________________
WA R NI N G
T h i s a p pl i c a t i onm u s t b e r e c
e i v e d b y t h e C o un t y
C l e r k n o t l a t e r t h a n7 d a y s pr i or t o t h e e l e c t i on ,
unl e s s y o u a p pl y i n p e r s on or v i a a n a u t h or i z e d
m e s s e n g e r d ur i n g C o un t y C l e
r k ’ s of c e h o ur s , b u t
n ol a t e r t h a n 3 P .M. t h e d a y pr i or t o t h e e l e c t i on.
P L E A S E N OT E
A v o t e r m a y a p p l y f o r a M a i l - I n B a l l o t b y m a i l u p t o 7 d a y s
p r i o r t o t h e e l e c t i o n .H e o r s h e m a y
a l s o a p p l y i n p e r s o n t o t h e
C o u n t y C l e r k u n t i l 3 P .M. t h e d a y b
e f o r e t h e e l e c t i o n .
N o t e
a l s o
t h a t v o t e r s h a v e
a n
o p t i o n
o f i n d i c a t i n g
o n
a n
a p p l i c a t i o n f o r a M a i l - I n B a l l o t t h a t t h e y w o u l d p r e f e r t o r e c e i v e
a b a l l o t f o r e a c h e l e c t i o n t h a t t a k e s
p l a c e d u r i n g t h e r e m a i n d e r
o f t h e c a l e n d a r y e a r .
V o t e r s a l s o n o w
h a v e a n o p t i o n o f a u t o m a t i c a l l y r e c e i v i n g a
M a i l - I n B a l l o t f o r e a c h G e n e r a l E l e c
t i o n .I f s u c h v o t e r n o l o n g e r
w a n t s t h i s o p t i o n , t h e C o u n t y C l e r k
’ s o f c e m u s t b e n o t i e d i n
wr i t i n g .
V OT I N GI NF OR MA T I ON
1 .Y o u m u s t b e a r e g i s t e r e d v o t e r i n
o r d e r t o a p p l y f o r a M a i l - I n
B a l l o t .
2 . O n c e y o u a p p l y f o r a M a i l - I n B a l l o t , y o u wi l l n o t b e p e r mi t t e d
t o v o t e b y m a c h i n e a t y o u r p o l l i n g p l a c e i n t h e s a m e e l e c t i o n .
3 .Y o u wi l l r e c e i v e i n s t r u c t i o n s wi t h
y o u r b a l l o t .
4 .Y o u r M a i l - I n B a l l o t m u s t b e r e c e i
v e d b y t h e C o u n t y B o a r d o f
E l e c t i o n b e f o r e c l o s e o f p o l l s o n
E l e c t i o n D a y .
5 .D o n o t s u b mi t m o r e t h a n o n e a p p l i c a t i o n f o r t h e s a m e e l e c t i o n .
6 .Y o u m u s t a p p l y f o r a M a i l - I n B a l l o t f o r e a c h e l e c t i o n , u n l e s s
y o u d e s i g n a t e o t h e r wi s e u n d e r
“ V o t e r O p t i on s .”
P l e a s e S e al wi t h T a p e an d R e t ur n
p p
· P r i n t a n d s i g n y o u r n a m e wh e r e i n d i c a t e d .
· M a i l or D e l i v e r a p p l i c a t i o n t o t h
e C o u n t y C l e r k .
H a n d d e l i v e r t o :
O f c e o f t h e C o u n t y C l e r k ,E l e c
t i o n D i v i s i o n ,
C o u n t y A d mi n i s t r a t i o n B u i l d i n g
6 0 0 M a r k e t S t r e e t , S u i t e 3 1 6 , C a m d e n N J
0 8 1 0 2
D O N O T F A X
O R
E - MA I L
U nl e s s y o u a r e a Mi l i t a r y or O v e r s e a s V o t e r
APPL I CATI ON
F OR
V OTE
BY
M
AI L
BAL L OT
A
PPL I CATI ON
F OR
V OTE
BY
M
AI L
BAL L OT
Kristin M. Corrado
Passaic County Clerk
401 Grand Street
Room 130
Paterson, NJ 07505
