Name:

Date of Birth:

Voter registration number (if available -- not required):

Brevard County residence address (REQUIRED):



Check if this is a change of your Brevard County residence address
Check if you do not have a permanent residence address in Brevard
County and are living outside of the county but intend to remain a permanent
resident of the county. (If this applies to you, do not enter an address
in the space above)

Address to mail ballot:
NOTE: By state law, if you have an address change or a forwarding order
filed with the Postal Service at the address you enter below, your absentee
ballot WILL NOT be forwarded to you. (This does not apply to members
of the military.)
Check to use Brevard County residence address listed above



Check if this is your permanent mailing address

Phone number:

E-mail address:

Select one or more elections for which you wish to receive ballots:

City Elections, November 3, 2009
Primary Election, August 31, 2010
General Election, November 2, 2010

OR select:

ALL ELECTIONS THROUGH NOVEMBER 2010

If you are making this request for someone other than yourself, you must give the following information about yourself:

Name:

Address:

Driver's license number (if available):

*Relationship to person whose ballot you are requesting:

* You may only request absentee ballots for yourself and (1) your immediate family, which is defined as your spouse, child, parent, grandparent, or sibling, or your spouse's child, parent, grandparent, or sibling, and (2) a person for whom you are legal guardian.

Additional comments:

Check here if you wish to be added to our list of voters who are mailed advance notices of elections. By checking this box you WILL NOT be on a permanent list to receive absentee ballots; we have no such list because Florida law does not allow voters to make absentee ballot requests for a period of more than the next two General Elections. You do not need to check this box if you are already receiving advance notices of elections.