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Complete Form and Return To:

Duchesne County Clerk/Auditor
Diane Freston
Drawer 910
734 North Center
Duchesne,  Utah  84021

 

APPLICATION FOR
ABSENT-VOTER BALLOT

I,                                                            am a registered voter  (voter's name as closely as it appears on registration roles) in full possession of my mental faculties.  My place of residence in Duchense  County is at the following street address, city and Zip Code:

 

                                                                                  

                                          (do not use a P.O. Box here)

 

and I believe that I am entitled to vote by absentee ballot. 

 

Please mail my ballot to me at the following address:

                                                                                      

                                               (may use a P.O. Box here)

 

I apply for an absentee ballot for the following elections (check the line that applies):

          Primary Election
          November Election
          Bond/Special Election

Place my name on the County permanent absentee voter list

      yes
      no

 

[Sign Here]                                                              
Date                                  20          

Application is not Valid Without Signature

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