Middlesex County Board of Elections Public Service Request
Requestor Name: Organization: Address:
__________________________________ ___________________________________ ___________________________________ I M P O R T A N
Date: Title: Phone #:
_____________________ _____________________ ( )______-_________
T
Commercial use of this information is prohibited per NJSA 19:31-18.1c. Requests are to be accompanied by a check or money order and a letter stating your reason for the request.
I N F O R M A T I O N
R E Q U E S T E D
1. Voter Registration for:(check one) Full County
Town(s)
_______________________________ _______________________________
Legislative District(s)
Congressional District(s) ______________________________ All Democrat Republican Independent Unaffiliated Constitutional Green Libertarian Natural Law Reform From _______________________ To ____________________ Absentee Voters Only 1 Per Household Complete Voter History (includes all elections) Election(s) _________________________________________ DBF SDF TXT
(please number from 1-6, number 1 being the highest priority)
2. Political Party(ies): 3. Registration Date(s): 4. Other Criteria:
5. Formatting: 6. Sort Sequence: 7. Output:
__City __District __Party __Voter Name __Street __Zip Code
(extra charge for more than 3000 labels)
a) Media b) Printout c) Labels
# of names
Media output will be supplied on CDROM One sided printout Two sided printout 3x across 2x across 1x across
total amount
8. Cost: (cost is calculated as follows) 9. Payment:
__________ X .0007 = $______________( min.$75.00 – max $250.00) Checks are made payable to: Middlesex County Treasurer Mail request to: Daniel Frankel, Scty./Commissioner of Registration Middlesex County Board of Elections 777 Jersey Ave. New Brunswick, NJ 08901
10. Requestor Signature:
____________________________________________________
FOR OFFICE USE ONLY
Approved by ______________________________ Ready for pickup date ______________________
Date ___________________________ Picked up Date___________________