Scheduling Order (Page 3 of 11) in pdf

EMERGENCY APPLICATION FOR ABSENTEE BALLOT

(For Erne encies That Occur After 5:00 P.M. on the Frida Before the Prima

or Election)

-------,""',...,.,"""~"""'...,.,,_;;_o;""""""""""""..,,___----- declare that I am a voter

(PLEASE PRINT NAME AS REGISTERED)

County, Pennsylvania, and that I am a qualified and registered elector

at my home address which is

(STREET ADDRESS OR RURAL ROUTE)

(pOST OFFICE

ANDJOR

ZIP CODE)

in the

Ward,

District, of the

that I have resided in this voting

- - - -

(CfrY/lJOROtrOViN.TOWNSHIP)

district since

and that I am entitled to vote therein Uris primary or election.

My occupation is

_ My date of birth is

(If employee of the Commonwealth or Federal Government qualified to vote without street address, check here. CJ)

MAIL BALLOT TO ME AT THE FOLLOWING ADDRESS,

IF'

APPLICABLE:

i---------------------------

f-------t-------------------------------------

ABSENCE FROM TIlE MUNICIPALITY

I expect to be absent from the municipality of my residence on the day of the election/primary because of duties,

occupation or business, which fact was not and could not be known to me on or before 5:00 P.M. on the Friday

prior to the election

(DATE OF SIGNING)

(SIGNATURE OF VOTER)

Sworn and subscribed before me this

day of

(SrAtE 1Il LE Of OFFICE, NotARY pOBLIc, Erc AFFIX SEAL)

1 - - - - - - - - - - - - + - - - - - - - - - - - - - - - , - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - ~

ILLNESS OR PHYSICAL DISABILITY

I expect to be unable to attend my proper polling place on the day of the election/primary because of illness or

physical disability. The nature of which appears below:

(IN

sHkt bIMBlE! ry ok ILLNESS:

HERE)

(DATE OF SIGNING)

(SIGNATORE OF VOTER)

I hereby attest that the physical disability or illness of above elector occurred at a time when he was unable to apply

for an absentee ballot, on or before 5:00 P.M on the Friday prior to the election.

(SIGNATURE OF PHYSICIAN)

Sworn and subscribed before me this _ _ day of

20_

The following to be completed if applicant is unable to sign because of illness or physical disability. I hereby state

that I am unable

sign my application for an absentee ballot without assistance because I am unable to write by

reason of my illness or physical disability. I have made, or have received assistance in making my mark in lieu of

my signature.

(DATE)

(MARK)

(COMPLETE ADDRESS IF WITNESS)

(SIGNATURE OF WITNESS)

NOTE: Electors requiring assistance in voting must procure Special Form from the county Board of Elections to

transmit with this application.

WARNING -

IF YOU ARE ABLE TO VOTE IN PERSON ON ELECTION DAY, YOU MUST GO TO YOUR POLLING

'---------__

PLACE, VOID YOUR ABSENTEE BALLOT AND VOTE THERE.

Scheduling Order Page 3

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