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Absentee Ballot Request
 
(Highlighted Items are required elements)
  
I would like to request an absentee ballot for the following election(s):
2008 General Election
2008 Municipal Runoff Election
Any Elections through 2008 for which I am eligible
Any Elections through 2010 for which I am eligible
Last Name:
 First Name:
 MI:
Registration #:
 Birthdate:
 Daytime Phone:
 Email Address:
Escambia County Residence Address: Choose One if Applicable
Military or Dependent
Civilian living out of USA
Disabled    Other
Mailing Address for Absentee Ballot:
(Required if different from Residence Address) 		 
   This mailing address is to be used
   only for the absentee ballot
 
Absentee ballots can be requested only by the voter, the voter's immediate family, or legal guardian.  If the requester is someone other than the voter, the requester must provide the following additional information.
Requester's Name:
 Date:
 Drivers Lic # (if available):
Requester's Address:
 Relationship to Voter: