Per Ma
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APPLICATION FOR PERMANENT VOTE BY MAIL STATUS
Dear Registrar-Recorder/County Clerk: I am currently a registered voter in Los Angeles County and am applying for Permanent Vote By Mail status. NAME: (PRINT) _________________________________________________________________________ DATE OF BIRTH:_________________________________________________________________________ REGISTERED ADDRESS: __________________________________________________________________ CITY: ______________________________________________________ ZIP CODE:___________________ SIGNATURE AS REGISTERED U____________________________________________________________ TELEPHONE NUMBER: (
DATE: ______________________
)____________________
Address where ballot will be mailed (if different from registered address) ADDRESS: (PRINT) _____________________________________________________________________ CITY: ____________________________________________________ ZIP CODE: ___________________ OFFICE USE ONLY
INPUT DATE
INTL
NOTIFICATION DATE
INTL
VID #
Registrar-Recorder/County Clerk 12400 Imperial Hwy., Norwalk, Ca 90650 USA Rev. 1/08
APPLICATION FOR PERMANENT VOTE BY MAIL STATUS Dear Registrar-Recorder/County Clerk: I am currently a registered voter in Los Angeles County and am applying for Permanent Vote By Mail status. NAME:
(PRINT)___________________________________________________________________________
DATE OF BIRTH:___________________________________________________________________________ REGISTERED ADDRESS:____________________________________________________________________ CITY:______________________________________________________ZIPCODE:______________________ SIGNATURE AS REGISTEREDU______________________________________________________________ DATE: ______________________
TELEPHONE NUMBER: (
)____________________
Address where ballot will be mailed (if different from registered address) ADDRESS: (PRINT)_________________________________________________________________________ CITY: ____________________________________________________ ZIP CODE: ______________________ OFFICE USE ONLY
INPUT DATE
INTL
NOTIFICATION DATE
INTL
VID #
Registrar-Recorder/County Clerk 12400 Imperial Hwy., Norwalk, Ca 90650 USA
Rev. 1/08
Dear Registrar-Recorder/County Clerk: I am currently a registered voter in Los Angeles County and am applying for Permanent Vote By Mail status. NAME: (PRINT) _________________________________________________________________________ DATE OF BIRTH:_________________________________________________________________________ REGISTERED ADDRESS: __________________________________________________________________ CITY: ______________________________________________________ ZIP CODE:___________________ SIGNATURE AS REGISTERED U____________________________________________________________ TELEPHONE NUMBER: (
DATE: ______________________
)____________________
Address where ballot will be mailed (if different from registered address) ADDRESS: (PRINT) _____________________________________________________________________ CITY: ____________________________________________________ ZIP CODE: ___________________ OFFICE USE ONLY
INPUT DATE
INTL
NOTIFICATION DATE
INTL
VID #
Registrar-Recorder/County Clerk 12400 Imperial Hwy., Norwalk, Ca 90650 USA Rev. 1/08
APPLICATION FOR PERMANENT VOTE BY MAIL STATUS Dear Registrar-Recorder/County Clerk: I am currently a registered voter in Los Angeles County and am applying for Permanent Vote By Mail status. NAME:
(PRINT)___________________________________________________________________________
DATE OF BIRTH:___________________________________________________________________________ REGISTERED ADDRESS:____________________________________________________________________ CITY:______________________________________________________ZIPCODE:______________________ SIGNATURE AS REGISTEREDU______________________________________________________________ DATE: ______________________
TELEPHONE NUMBER: (
)____________________
Address where ballot will be mailed (if different from registered address) ADDRESS: (PRINT)_________________________________________________________________________ CITY: ____________________________________________________ ZIP CODE: ______________________ OFFICE USE ONLY
INPUT DATE
INTL
NOTIFICATION DATE
INTL
VID #
Registrar-Recorder/County Clerk 12400 Imperial Hwy., Norwalk, Ca 90650 USA
Rev. 1/08
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