PLEASE NOTE: Your ballot can only be sent to the mailing address supplied on this application.
If your mailing address changes, you must notify the County Clerk in writing.
1
r ALL FUTURE ELECTIONS, until I request otherwise in writing.
Or for ONLY ONE of the following: r General (November)
r Primary (June) r Municipal r School r Fire
r Special _______________ To be held on
I hereby apply for a Mail-In Ballot for:
(CHECK ONLY ONE)
8
Signature: I arm that I am the person
who is applying for this ballot and I live at the
address designated in box 3 of this form.
X _____________________
Please type or print clearly in ink. All information required unless marked optional.
9
Today’s Date
(MM / DD / YYYY)
/ /
/ /
(Specify)
(MM / DD / YYYY)
r
Same Address as Section 3
Address at which you are registered to vote:
Apt.
Municipality
(City/Town)
State Zip
Street Address or RD#
3
I request Vote-By-Mail Ballots for all elections in which I am
eligible to vote and I am (CHECK ONLY ONE)
MILITARY/OVERSEAS VOTER ONLY
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.
r
A U.S. Citizen residing outside the U.S. and I have never lived in the U.S.
Application For Vote by Mail Ballot
Mail my ballot to the following address:
4
Please include
any PO Box, RD#,
State/Province,
Zip/Postal Code
& Country
(if outside US)
5
6
Date of Birth
(MM / DD / YYYY)
Day Time Phone Number
/ /
( )
7
E-Mail Address
10
Assistor: Any person providing assistance to the voter in completing this application must complete this section.
11
Address Apt.
Municipality
(City/Town)
State Zip
Name of Assistor
(Type or Print)
Date
(MM / DD / YYYY)
Signature of Assistor
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 qualied voters per election, except that an authorized
messenger or bearer may serve as such for up to ve qualied voters in an election if those voters are immediate family members
residing in the same household as the messenger or bearer.
I designate ____________________________________________ to be my Authorized Messenger.
X
Authorized Messenger must sign application and show photo ID
in the presence of the County Clerk or County Clerk designee.
/ /
Print Name of Authorized Messenger
Address of Messenger Apt. Municipality
(City/Town)
State
Zip
“I do hereby certify that I will deliver the Mail-In Ballot directly to the voter
and no other person, under penalty of law.”
STOP
Date of Birth
(MM / DD / YYYY)
/ /
OPTIONAL - ONLY COMPLETE SECTIONS 10 OR 11 IF APPLICABLE
NJ Division of Elections - 02/28/21
2
Last Name
(Type or Print)
First Name
(Type or Print)
Middle Name or Initial
Sux (Jr., Sr., III)
Date
(MM / DD / YYYY)
Signature of Messenger
X
/ /
OFFICE USE ONLY
Voter Reg # ____________________________
Muni Code #_______ Party _______________
Ward __________ District ________________
Date
(MM / DD / YYYY)
Signature of Voter
X
/ /
PLEASE NOTE: This contact information will be used to contact you concerning the acceptance or rejection of your ballot and how you may cure a defect.
APPLICATION FOR VOTE BY MAIL BALLOT
Name
Street Address
City, State, Zip Code
_________________________________
_________________________________
_________________________________
WARNING
This application must be received by the County
Clerk not later than 7 days prior to the election,
unless you apply in person or via an authorized
messenger during County Clerk’s oce hours, but
no later than 3 P.M. the day prior to the election.
PLEASE NOTE
A voter may apply for a Mail-In Ballot by mail up to 7 days prior
to the election. He or she may also apply in person to the County
Clerk until 3 P.M. the day before the election.
Voters now have an option of automatically receiving a Mail-In
Ballot for all future elections. If such voter no longer wants this
VOTING INFORMATION
1. You must be a registered voter in order to apply for a
Mail-In Ballot.
2. Once you apply for a Mail-In Ballot, you will not be permitted
to vote by machine at your polling place in the same election.
3. You will receive instructions with your ballot.
4. If returning your Mail-In Ballot in person it must be received
by the County Board of Elections before close of polls on
Election Day. If returning your Mail-In Ballot by mail, it must
be postmarked no later than Election Day and received by
the county board of elections no later than 144 hours (6 days)
after the time for the closing of the polls of the election.
5. Do not submit more than one application for the same election.
6. You must apply for a Mail-In Ballot for each election, unless
you designate otherwise under Section 1.
Please Seal with Tape and Return
INSTRUCTIONS
· Fill out application.
· Print and sign your name where indicated.
· Mail or Deliver
application to the County Clerk.
Hand deliver to:
Oce of the County Clerk, Election Division,
County Administration Building
600 Market Street, Suite 316, Camden NJ 08102
DO NOT FAX OR E-MAIL
Unless you are a Military or Overseas Voter
Application
For
Vote by
Mail Ballot
Application
For
Vote by
Mail Ballot
John S. Hogan
Bergen County Clerk
One Bergen County Plaza, Room 130
Hackensack, NJ 07601
