Scheduling Order Page 4
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11Designation of Authorized Representative
to Assist Emergency Absentee Ballot Applicant
Court of Common Pleas of
----------:~-----
(Insert Name
of
County)
I hereby designate
_ _
~
ro serve
as
my
(Insert Name ofAuthorized Representative)
agent for obtaining an emergency absentee ballot for my use only and to return the ballot
after I have completed it and sealed it in the required envelope to the Board of Elections of
_ _ _ _ _ _ _ County. I understand that my completed ballot must be returned to the
Board of Elections no later than 8:00 P.M. on the day of the primary or election. I am
qualified under Pennsylvania law to vote by emergency absentee ballot because of illness or
physical disability that occurred after 5:00 P.M. on the Friday before the primary or election
or because
I
will be absent from my municipality on the day of the primary or election
because of my business, duties or occupation, which fact was not and could not reasonably
be known prior to 5:00 P.M, on the Friday before the primary or election.
(Address of Voter)
(Voter's Signature)
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