SAMPLE ABSENTEE BALLOT REQUEST FORM

Today's Date: _________________________

Member who is nominating (i.e., person filling out this form)

Name: ______________________________

Building/Apartment: _________ / _________

Telephone: ____________________ Best Time to Call: ____________

E-Mail Address: _____________________________ (only for E-mail nominations)

 

Method for Receiving Absentee Ballot (check one):

_ Web (see http://islandhouse.us after January 18-21)

_ E-Mail, what is your E-mail address? ___________________________________

_ Phone, what is your phone number? ___________________________________

_ Fax, what is your fax number? ___________________________________

 

Method for Sending Absentee Ballot (check one):

_ Postal Mail

_ Courier

_ Fax

_ Email

Note #1: Absentee Ballots are due Noon January 26, Eastern Time

Note #2: Your absentee ballot will include the appropriate return address