Application for Absentee Ballot

                                                                                     PLEASE PRINT OR TYPE 

                                                                                           Send Ballot to:

                                                                                                                (if different from home address)

Voter’s Name_________________________________          Name_________________________________________

Home Address________________________________           Care of/PO Box_________________________________

City, Village, or Post Office_____________________             Address_______________________________________

County__________________Zip Code____________             City________________State_____Zip Code__________

 You must provide your birthdate: ________/________/________and one of the following:

                                                                                                          month                  day               year

                                Your Ohio driver’s license number________________________, or

                        The last four digits of your social security number_________________, or

                        Copy of current and valid photo identification, a current utility bill, bank statement,

                        government check, paycheck or other government document that shows your name and address.

                I wish to vote in the following election to be held on Nov. 2, 2010.

I wish to have a ballot mailed to me at the address listed above. I understand that if a ballot

is mailed to me and I change my mind and appear at my polling place to vote on Election

day, I will be required to vote a provisional ballot that can not be counted until at least 10

days after the election.

            I hereby declare, under penalty of election falsification, I am a qualified voter and the statements above are 

                true to the best of my knowledge and belief.  I understand that if I do not provide the requested information,

                my application cannot be processed.

                        X_____________________________________________      _____________________

                                                     Signature of Voter                                                                                        Date Signed

To assist the Board of Elections in contacting you in a timely manner if your application is incomplete:

Your daytime telephone number ___________________   Your e-mail address _____________________________

            Please Return Application to:

                               Ashland County Board of Elections

                                110 Cottage St.

                                Ashland, OH 44805

            Any questions, please call 419-282-4224