APPLICATION FOR ABSENTEE BALLOT
 Name:   Mail Ballot to:
 Home Address:  
 Post Office:   
 Date of Birth: 

IF YOU WILL BE ABSENT FROM YOUR MUNICIPALITY ON ELECTION DAY, COMPLETE SECTION A

SECTION A - I expect to be absent from my municipality on the day of the coming primary / election because of duties, occupation, business, observance of religious holiday.

 Reason For Absence:

______________________________

Signature of Elector 

 Date

IF YOU ARE ILL OR PHYSICALLY DISABLED - COMPLETE SECTION B

SECTION B - I expect to be unable to attend my proper polling place on the day of the coming primary / election because of illness or physical disability, disability, the reason which appears below:

Insert illness or disability

Name of Physician

 Date

Address of Physician 

 Phone Number
(IF UNABLE TO SIGN, COMPLETE LAST SECTION BELOW)

______________________________

Signature of Elector 

Date

THE FOLLOWING IS TO BE COMPLETED IF APPLICANT IS UNABLE TO SIGN BECAUSE OF ILLNESS OR PHYSICAL DISABILITY
I hereby state that I am unable to sign my application for absentee ballot without assistance because I am unable to write by reason of my illness or physical disability. I have made or received assistance in making my mark in lieu of my signature. NOTE: Electors requiring assistance in voting must procure a Special Form from the county Board of Elections to send in with this application.

______________________________

Date 

Signature of Witness

______________________________

My Mark 

Address of Witness


AFTER PRINTING, PLEASE SIGN AND MAIL COMPLETED APPLICATION TO:
Voter Registration
Lehigh County Government Center
17 S. Seventh St.
Allentown, PA 18101-2400