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

1. Election

2. Name

3. Date of Birth (*REQUIRED)

(eg. 01/31/1900)

4. Residence Address

(Where you live)

5. Mailing Address

(Where you receive your mail)

6. Email Address

7. Phone Number

8. Cross-Over Party

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.