FOR Civilian Voters Living in the U.S.:

Voter’s Name:___________________________________________________________ (First, Middle, Last Name)

Check if last name is different than when you registered to vote--Former Name: _________________________

Voter’s Current Mailing Address: __________________________________________________________________

Voter’s Town of Residence: ______________________________________________________________________

Telephone Number: _____________________ Email Address: __________________________________________

I request early voter ballot(s) for the election(s) checked below:

Annual Town Meeting August Primary Election

Special Town Meeting: __/___/_____ November General Election

date March Presidential Primary (next in 2012)

I would like the ballot(s) delivered as indicated below (CHECK ONE):

Mail to voter at: _________________________________________________________________________

Street or PO Box Town/City State Zip Code

Deliver by two Justices of the Peace (This may only be selected if you are ill or physically disabled.)

__________________________________________________ ________________

Signature of Absentee Voter or Authorized Person Date

REQUEST FOR EARLY OR ABSENTEE VOTER BALLOT for 2010 (ONE YEAR ONLY)

(All voters including military and overseas voters must now submit a new request for absentee ballots each year.)

(SUBMIT DIRECTLY by fax, email or mail to the Town Clerk of the town in which you are on the voter checklist.)

FOR Voters serving in MILITARY (active U.S. or overseas) and OVERSEAS Voters:

Check one: Military (Active in U.S. or overseas) Overseas voter (not military)

Voter’s Name:___________________________________________________________________________________

Voter’s VT Town of Residence (before joining military or moving overseas): _________________________________

Please deliver ballot(s) and all election materials as indicated below (check one):

E-mail Address: __________________________________________________

(Blank ballot will be delivered by e-mail to the voter. All voted ballots must be mailed or sent by a

delivery service to the town clerk.)

Fax to fax number: __________________________________ (You must provide country codes and all other

codes or numbers necessary to fax successfully to the number provided from a VT telephone.)

Regular mail delivery to: (Print exactly as necessary to complete delivery to you.)

_____________________________________________

_____________________________________________

_____________________________________________

IF YOUR INFORMATION for the delivery method selected above CHANGES during the year, you must notify your town

clerk of your new contact or delivery information in order to receive your ballots--this is the voter's responsibility.

_________________________________________________ ________________

Signature of Absentee Voter or Authorized Person Date

IF YOU ARE REQUESTING A BALLOT FOR SOMEONE OTHER THAN YOURSELF, you must complete the

information below: (family member, health care provider, or person authorized by the absentee voter):

Name of Applicant: _____________________________________________ Date: _______________

Address of Applicant: __________________________________________________________________________

Street Town/City State Zip Code

Relationship to Voter (check one): Family member Health care provider Person authorized by voter Civilians Living in the U.S. Military and Overseas Voters Please Note:

For Clerks Use Only: Voted at town clerk’s offi ce

Ballot picked up at town clerk’s offi ce

In pdf format:   Absentee Ballot in pdf format