VOTE BY MAIL BALLOT APPLICATION

Any voter may request to be a Permanent Vote by Mail Ballot Application, please complete this form. A vote by mail ballot will automatically be sent to you for future elections. Failure to return a vote by mail ballot for two consecutive statewide general elections will cancel your Vote By Mail Ballot Application Voter Status and you will need to reapply. If you have any questions concerning voting by Vote by Mail ballot, please call the Sacramento County Registrar of Voters at 916-875-6451. (Elections Code Section 3201, 3206)  

PRINT NAME: ______________________________________ DATE OF BIRTH  ________________                                                               (First)                          (Middle)                         (Last)  

RESIDENCE ADDRESS IN SACRAMENTO COUNTY (Please Print)

_____________________________________________________________________________________
                          Number and Street (P.O. Box, Rural Route, etc. not acceptable - designate N, S, E, W, if used)  

_________________________________________________________________________________________________________                                      (City)                                                             (State or County)                                   (Zip Code)

TELEPHONE NUMBER (_____ )___________________________ (____ )_________________________

EMAIL ADDRESS: _____________________________________________________________________

ADDRESS WHERE BALLOT IS TO BE MAILED, IF DIFFERENT FROM YOUR ADDRESS: Note: Organizations distributing this form may not preprint mailing address.
_____________________________________________________________________________________________
(Number and Street/P.O. Box)

 ____________________________________________________________________________________________________________                                          (City)                                                 (State or County)                                   (Zip Code)

THIS APPLICATION WILL NOT BE ACCEPTED WITHOUT THE PROPER SIGNATURE OF THE APPLICANT
 I certify under penalty of perjury under the laws of the State of California that the name and residence on this application are true and correct.

X ___________________________________________________________                        Signature or mark an "X" if unable to sign (Power of Attorney NOT Accepted)           Date

If the voter is unable to sign, s/he may make a mark witnessed by at least one person. ____________________________                                                                                                                                                                             Witness
WARNING: Perjury is punishable by imprisonment in State prison for two, three or four years. (Section 126 of the Ca. Penal Code)

THIS FORM IS PROVIDED BY: REPUBLICAN PARTY OF SACRAMENTO COUNTY, 1325 Howe Avenue, Suite 105, Sacramento CA. 95825  Phone (916) 925-1850 

NOTICE: You have the legal right to mail, fax or deliver this application directly to the local elections official where you reside. This address is:

Sacramento County Voter Registration and Election Department
7000 65th St. Suite A
Sacramento, CA 95823

Office (916) 875-6451

Returning this application to anyone other than your elections official may cause a delay that could interfere with your right or ability to vote. 

The format used on this application must be used by ALL individuals, organizations and groups that distribute vote by mail ballot applications. Failure to conform to this format may result in criminal prosecution. (Elections Code Section 3007 & 18402)