Absentee Ballot Request

Name * _________________________________________________

Social Security Number or Voter ID Number:___________________

Birth Date:___________________ Sex: _____________

Please send an absentee ballot to me at the address indicated above for the

* _____________________________ Election to be held on

* _____________________________, 2003.

Address at Which Registered to Vote:

* ___________________________________________

* ___________________________________________

* ___________________________________________

Address to Which Ballot is to be Mailed, if Different:

____________________________________________

____________________________________________

____________________________________________

Signature of Voter

* ____________________________________________