Vote By Mail Ballot Request
Santa Cruz County California
June 5, 2012 Presidential Primary Election

IMPORTANT: You must enter the requested information in ALL THE FIELDS MARKED WITH * below.
VOTER INFORMATION WILL BE USED FOR OFFICIAL PURPOSES ONLY
You MUST be registered to Vote in Santa Cruz County.

Military or Temporary Overseas Voters Not Yet Registered to Vote, Please Click Here
Citizens Residing Outside U.S. Territory Please Click Here

DEADLINE: 5 p.m., May 29, 2012
For overseas voters, we suggest you apply by April 21, 2012

You MUST be registered to Vote in California. Please click here to check your status. Click here if you need to re-register. You must re-register every time you move your place of residence.

This application must be received by the Santa Cruz County Elections Department in person, by mail, by FAX or by clicking SUBMIT FORM below. If there's a problem submitting over the internet, please print out this form and then fax or mail to:

SANTA CRUZ COUNTY ELECTIONS DEPARTMENT
701 OCEAN ST RM 210
SANTA CRUZ CA 95060-4076
FAX: 831-454-2445

* * * PRESS TAB TO ADVANCE TO NEXT FIELD * * *

Full Name:
*

I request a paper ballot be mailed to me early as I am in the military or residing overseas. 60-day Ballots are mailed beginning April 6, 2012.*

 OR

I request a vote-by-mail ballot to be mailed to me during the regular vote-by-mail period: May 7 to May 29, 2012.*

Birthdate:
*
Email Address:

SANTA CRUZ COUNTY ADDRESS REQUIRED (for voting purposes - If you live outside Santa Cruz County, click here for explanation) Please do not use P.O. Box Number or other mailing address

Street Number and Name:
*

City, State and Zipcode:
*

Daytime Telephone (optional):

Other Telephone (optional):

MAILING ADDRESS FOR BALLOT (If different from above):

Number and Street or P.O. Box Number:

City, State and Zipcode:

If applicable:
I have declined to disclose a preference for a qualified political party. However, for this primary election only, I request a vote by mail ballot for the:

Democratic Party

American Independent Party

A ballot without the contest for President

CERTIFICATION. "I have not applied for, nor do I intend to apply for, a vote-by-mail ballot from any other jurisdiction for this election. By submitting this application, I certify under the laws of the State of California that the name and residence address and information I have provided on this application are true and correct."

Only the registered voter himself or herself may apply for a vote-by-mail ballot. An application for a vote-by-mail ballot made by a person other than the registered voter is a criminal offense

A BALLOT WILL NOT BE SENT TO YOU IF THIS APPLICATION IS INCOMPLETE OR INACCURATE.

Any voter may apply for PERMANENT VOTE-BY-MAIL STATUS (§3201). Check here to receive a vote-by-mail ballot for all future elections.

If online submission fails, please click here, download and print this form then deliver by mail, in person or by FAX