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 24-28)
                _ 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 February 1, Eastern Time

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