Replacement Vote By Mail Ballot Request

To obtain a Vote by Mail Ballot, complete the information on this form.

1. Election

Election (*REQUIRED)

2. Name

FIRST NAME (*REQUIRED)

MIDDLE NAME OR INITIAL

LAST NAME (*REQUIRED)

YOU MUST BE A REGISTERED VOTER IN THE COUNTY OF ALAMEDA

3. Date of Birth (*REQUIRED)

(eg. 01/31/1900)

Month

Day

Year

4. Residence Address

(Where you live)

Number and street - as registered (*REQUIRED)

City (*REQUIRED)

State

Zip Code (*REQUIRED)

5. Mailing Address

(Where you receive your mail)

Number and street - as registered

City

STATE

COUNTRY

Zip Code

6. Email Address

Email Address

7. Phone Number

Phone Number

8. Cross-Over Party

I have declined to disclose a preference for a qualified political party. The below-listed political parties are allowing crossover voting in this election. For this election only, I request a ballot for the following political party (select only one):

Party

Notice to No Party Preference/Nonpartisan voter ONLY

Terms

I have not applied for, nor do I intend to apply for, a vote by mail ballot from any other jurisdiction for this election. By submitting this application, I certify under the laws of the State of California that the name and residence address and information I have provided on this application are true and correct.

Only the registered voter himself or herself may apply for a vote by mail ballot. An application for a vote by mail ballot made by a person other than the registered voter is a criminal offense.