EFTA00520764.pdf

ELECTION SYSTEM OF THE VIRGIN ISLANDS Sunrq, Isle Annex Unit 4 Christiansted, vi I Box 1499 ffingshal, VI 00851 9203 Lockhart Garden Shopping St. Thomas, VI I Boa 6038 St. Thomas, VI 00804 Website: ABSENTEE BALLOT APPLICATION AI'PUCATION INTORMATION TYPE OA PRINT ONLY Name: Sex: MaleOFemale Q (As WS on th• ofter 11•0statko. Cana Last Four Digits of SS Number; Date of Birth: SpUtlq Place of Birth: eaCke Cp.{ Party Affiliation: (Select only one) DemoaatQ RepublicanO ICM No Party€ Local Physical Address (No. and Street) BB Utile SI James, SI Thomas, Virgin Islands 00602 (As listed on registration card) Local Mailing Address: 6100 Red Hook Ouaner Ste B3. SI Thomas, Virgin Islands 00802.1348 Telephone: /Work Home Cellular Fax Email Address; -cam MAIL ABSENTEE BALLOT TO: (Complete moiling address where you want ballot to be moiled) 575 lfrEckSon Avenue 4th Floor New York, Now York 10022 METHOD OF PREFERENCE IN RECEIVING APPLICATION OR BALLOT: WALX'IN_ MAIL.iN_ (Mail (MILITARY ONLY( REASON FOR ABSENTEE BALLOL(MARK X ONLY ONE): a. Member of the Armed Forces and Spouse or dependent b. A student residing outside the Territory c. An officer or employee of the Government of the Virgin Islands or Government of the U.S. d. Unable to appear because of illness or physical disability (permanent or temporary) e. A patient in a hospital, nursing home or home for the aged I. Absent from District because of accompanying a spouse, parent or child who would be entitled to apply for the right to vote by Absentee ballot O g. Detained in jail awaiting action by a grand jury or trial, or has been confined in prison after a conviction for an offense other than a felony Ka h. Any person who has not been out of the election district for more than 90 days prior to the date of the election for which an absentee status is sought 0 I. Religious grounds Ill uEST AN ABSE Tl, BAUOTFOR PRIMARY i GENERAL oLELCOLNG nIA witurAL ,LOElections Nis, ' conducted In the calendar year f al RE Cf VOTER or Voter esentative DATE I swear or affirm to the self-administered oath, under penalty of penury that: A. I am a United States Citizen, eligible to vote in the United States Virgin Islands. B. I have not been convicted of a felon or other disqualifying offense a been adjudicated mentally incompetent, or if so my voting rights have been reinstated. C. I am not requesting a ballot from or voting in any other State, Territory, or Possession or Subdivision of the United States or Foreign country in the coming election(%) D. That I meet all the qualifications of a Vixen Islands elector. E. The on this form is true and correct. FOR OFFICIAL USE ONLY - onetime Wier YES NO aW bred &Not Attune, Appiketlen IP4Plated 005011 EFTA00520764