Form Av-E1 - Application For Emergency Absentee Ballot

APPLICATION FOR EMERGENCY ABSENTEE BALLOT

Return this application to:

FORM AV-E1

______________________ COUNTY, ALABAMA

General Voter Information -

Please provide complete information so that we may verify your eligibility to vote.

Last Name (Please print)

First Name

Middle or Maiden Name

E-mail Address

Street Address (address where you are registered to vote; do not use PO box)

City

ZIP

Mail my ballot to the address where I regularly receive mail, if different from the street address provided above.

Precinct where you vote (name and/or location of your polling place)

Date of Birth

Driver’s License Number

Month

Day

Year

IF NO DRIVER’S LICENSE NUMBER

Last 4 digits of

Home Telephone Number

Work Telephone Number

Social Security

(

)

number

(

)

STATE

NUMBER

For all registered voters

I hereby make application for an absentee ballot so that I may vote in the following election:

Primary Election or Presidential Preference Primary

Primary Runoff Election

Select one:

Democratic Party

Republican Party

Other ____________

Amendments Only

General Election

Municipal Election

Special Election (specify) ________________________

Absentee ballots for elections more than 42 days apart must be requested on separate applications, unless you are a member

or a spouse or dependent of such person,

of the armed forces,

or you are a United States citizen residing overseas.

or a spouse or dependent of such person,

An application submitted by a member of the armed forces,

or a United States

citizen residing overseas, is valid for all county, state and federal elections in the current calendar year.

I will be unable to vote at my regular polling place on election day because (check one reason):

I have a medical emergency. Complete the Physician’s Report below. The physician’s report must be signed by a

physician. [If the physician’s report is on a separate document, attach it to this application. This application may be

delivered by a designee. If assigning a designee, complete the Designee section at the bottom of this form.]

I have a business emergency. By signing this application, I do solemnly swear or affirm that I was not aware of

the out-of-county business requirement prior to the five (5) days before the election. [The voter must deliver the

application by hand to the Absentee Election Manager during the five (5) days prior to the election.]

When I apply for this absentee ballot, I understand that my name will be stricken from the list of qualified electors and,

when I cast this absentee ballot, I understand that I will not be entitled to vote at my regular polling place.

Voter’s Signature

Complete this

Witness Signature



section if voter

Print Witness Name

signs by mark

The voter, or his or her designee in the case of a medical emergency, may hand this application to the Absentee Election

Manager. Except in the case of a business emergency, the voter may also forward this application to the Absentee

Election Manager by U.S. Mail [§17-11-3 and §17-11-4, Code of Alabama, 1975].

READ PENALTIES ON BACK

PHYSICIANS REPORT FOR MEDICAL EMERGENCY

Physician shall describe and certify the circumstances as constituting the emergency.

Physician’s Signature

Date

ASSIGNMENT OF DESIGNEE FOR DELIVERY OF APPLICATION

An application for an emergency medical absentee ballot may be forwarded to the Absentee Election Manager by the

applicant or his or her designee. If assigning a designee, complete this section.

Printed Name of Designee

Signature of Designee

For Office Use Only

Form Av-E1 - Application For Emergency Absentee Ballot - Alabama

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