Details for ATL CO CLERK - RETAIL

Updated

NOTICE TO PERSONS WANTING MAIL-IN BALLOT
GENERAL ELECTION
NOVEMBER 7, 2017

If you are a qualified and registered voter of the State who wants to vote by mail in the General Election in the County of Atlantic, New Jersey
to be held on November 7, 2017 complete the application form below and send to the undersigned, or write or apply in person to the undersigned
at once requesting that a mail-in ballot be forwarded to you. The request must state your home address and the address to which the ballot should
be sent. The request must be dated and signed with your signature.
If any person has assisted you to complete the mail-in ballot application, the name, address and signature of the assistor must be provided
on the application and, you must sign and date the application for it to be valid and processed. No person shall serve as an authorized messenger
for more than three qualified voters in an election. No person who is a candidate in the election for which the voter requests a mail-in ballot may
provide any assistance in the completion of the ballot or may serve as an authorized messenger or bearer.
No mail-in ballot will be provided to any applicant who submits a request therefore by mail unless the request is received at least seven days
before the election and contains the requested information. A voter may, however, request an application in person from the county clerk up to 3
p.m. of the day before the election.
Voters who want to vote only by mail in all future general elections in which they are eligible to vote, and who state that on their application
shall, after their initial request and without further action on their part, be provided a mail-in ballot by the county clerk until the voter requests
that the voter no longer be sent such a ballot. A voter’s failure to vote in the fourth general election following the general election at which the voter
last voted may result in the suspension of that voter’s ability to receive a mail-in ballot for all future general elections unless a new application is
completed and filed with the county clerk.
Voters also have the option of indicating on their mail-in ballot applications that they would prefer to receive mail-in ballots for each election
that takes place during the remainder of this calendar year. Voters who exercise this option will be furnished with mail-in ballots for each election
that takes place during the remainder of this calendar year, without further action on their part.
Application forms may be obtained by applying to the undersigned either in writing or by telephone, or the application form provided below
may be completed and forwarded to the undersigned.
Dated: September 14, 2017
Edward P. McGettigan
Atlantic County Clerk
5901 Main Street, Mays Landing, NJ 08330
(609) 625-4011 or (609) 641-7867

ApplicAtion For Vote

by

I request Vote-By-Mail Ballots for all elections in which I am
eligible to vote and I am (MARK ONLY ONE)

I hereby apply for a Mail-In Ballot for the:

1

(CHECK ONLY ONE)

r General (November)

r Primary

r Special _______________
(Specify)

2

r Municipal

r School

r Fire

/
/
To be held on ______________
(Date)

5
8

Municipality (City/Town)

State

Date of Birth

/
/
Signature

Mail my ballot to
the following address:

Apt.

Street Address or RD#

6

Day Time Phone Number

(

Same Address as Section 3

Please include
any
PO Box, RD#,
State/Province,
Zip/Postal Code
& Country
(if outside US)

4

Zip

Suffix (Jr., Sr., III)

Middle Name or Initial

Address at which you are registered to vote

3

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 return.

First Name (Type or Print)

Last Name (Type or Print)

MAil bAllot

MILITARY/OVERSEAS VOTER ONLY

Please type or print clearly in ink. All information required unless marked optional.

7

)

E-Mail Address (Optional)

Please sign your name as it appears in the Poll Book.

9

X ______________________________

Today’s Date

/

/

OPTIONAL - ONLY COMPLETE SECTIONS 10 THROUGH 12 IF APPLICABLE

Voter Options to Automatically Receive Ballots in Future Elections

10

You 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

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.

*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.

Assistor

Any person providing assistance to the voter in completing this application must complete this section.

11

Name of Assistor (Type or Print)

Date

Signature of Assistor

X
Address

Apt.

/

Municipality (City/Town)

State

/

Zip

Authorized Messenger

Any voter may apply for a Mail-In Ballot by Authorized Messenger. Messenger shall be a family member or a registered voter of this
County. No Authorized Messenger can (1) be a Candidate in the election for which the voter is requesting a Mail-In Ballot or (2) serve
as messenger for more than THREE qualified voters per election.

I designate ____________________________________________ to be my Authorized Messenger.
Print Name of Authorized Messenger

Address of Messenger

12

Apt.

Municipality (City/Town)

State

Zip

Date of Birth

/
Signature of Voter

STOP

/
/
Date
X _____________________________________________

Authorized Messenger must sign application and show photo ID
in the presence of the County Clerk or County Clerk designee.

“I do hereby certify that I will deliver the Mail-In Ballot directly to
the voter and no other person, under penalty of law.”
Signature of Messenger
Date

X

NJ Division of Elections - 08/15

/

/

/

OFFICE USE ONLY
Voter Reg # ____________________________
Muni Code #_______ Party _______________
Ward __________ District ________________

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