Civilian Absentee Ballot Application

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					              Division of                           Civilian Absentee Ballot Application
              Elections                                                        N.J.S.A. 19:57-1 et seq.

      You Must Apply for an Absentee Ballot for Each Election                            J * I am permanently and totally disabled and wish to receive an
                                                                                             absentee ballot for all elections to be held during the remainder of
I hereby apply for an absentee ballot for the (check one):                                   the calendar year.
  J Primary                     J General               J Municipal               J Observance of a religious holiday on election day.
  J Special                     J Local School          J Regional School         J Resident attendance at a school, college or university on election day.
  J Voc. Tech. School           J Other:                                          J Of nature and hours of my employment on election day.
                                                                                  Under penalty of Law, I certify that the foregoing statements made by me are true and correct
  To be held on

Check and Complete                                                                             Sign your name as it appears in the Registry Book
I live in the
   J City     J Town       J Township         J Borough         J Village of                                    Print or Type Your Name
  Name:                                                                          If sick or confined a voter may apply for an absentee ballot by authorized
  Street Address:
                                                                                  I designate,
                                                                                                                        (Name of Messenger)
  Zip Code:                       Phone Number:                                                                          (Signature of Voter)

                                                                                          Authorized messenger must sign application only in presence
Mail my Ballot to the Following Address:                                                           of County Clerk or County Clerk designee.
                                                                                  (Messenger must be a family member or a registered voter, N.J.S.A. 19:57-4)
  Street Address:
  Municipality:                                                                   Signature of Messenger:

  State:                              Zip Code:                                   Street Address:

Check Reason for Ballot                                                           Municipality:                                                 Zip Code:
N.J.S.A. 19:57-3
                                                                                Please Note:
I am unable to vote at my regular polling place on election day because:          A voter may apply for an absentee ballot by mail up to 7 days prior to the election.
  J I expect to be absent from the State of New Jersey on election day.           He or she may also apply in person to the County Clerk until 3:00 p.m. the day
                                                                                  before the election. Applications are to be returned to the County Clerk in the
     Departure Date:                                                              County of your last domicile in New Jersey. County Clerk listing are on the reverse
  J Of illness or temporary physical disability.                                  side (or page 2) of this form.
  J I am permanently and totally disabled, State reason:                          * Permanently and totally disabled voters have the option of indicating on an application for an
                                                                                  absentee ballot that they would prefer to receive an absentee ballot for each election that
                                                                                  takes place during the remainder of the calendar year.
                 Division of
                 Elections                                            County Clerks

Atlantic County Clerk                  Essex County Clerk              Monmouth County Clerk        Sussex County Clerk
Clerk’s Office                         P.O. Box 690                    300 Halls Mill Road          4 Park Place
5901 Main Street                       Newark, NJ 07101-0690           Freehold, NJ 07728-1254      Newton, NJ 07860-1795
Mays Landing, NJ 08330-1797            • 973-621-4921                  • 732-431-7324               • 973-579-0900
• 609-641-7867                         • Fax: 973-621-2527/2537        • Fax: 732-409-4887 and      • Fax: 973-383-7493
• Fax: 609-625-4738                                                           732-409-7566
                                       Gloucester County Clerk                                      Union County Clerk
Bergen County Clerk                    PO Box 129                      Morris County Clerk          Court House
One Bergen County Plaza                1 North Broad Street            PO Box 315                   2 Broad Street
Room 130                               Woodbury, NJ 08096-3327         Morristown, NJ 07963-0315    1st Floor, Room 115
Hackensack, NJ 07601                   • 856-853-3241                  • 973-285-6066               Elizabeth, NJ 07207-6099
• 201-336-7020                         • Fax: 856-853-3327             • Fax: 973-285-5233          • 908-527-4998/4999
• Fax: 201-336-7002                                                                                 • Fax: 908-558-2589
                                       Hudson County Clerk             Ocean County Clerk
Burlington County Clerk                583 Newark Avenue               PO Box 2191                  Warren County Clerk
PO Box 6000                            Jersey City, NJ 07306-2018      Toms River, NJ 08754-2191    413 Second Street
Mount Holly, NJ 08060-6000             • 201-795-6112                  • 732-929-2018               Court House
• 609-265-5189                         • Fax: 201-795-2581             • Fax: 732-349-4336          Belvidere, NJ 07823-1500
• Fax: 609-265-0696                                                                                 • 908-475-6214
                                       Hunterdon County Clerk          Passaic County Clerk         • Fax: 908-475-6208
Camden County Clerk                    P.O. Box 2900                   401 Grand Street
Election Division                      Hall of Records                 Room 130
PO Box 150                             Flemington, NJ 08822-2900       Paterson, NJ 07505
Camden, NJ 08101-0150                  • 908-788-1214                  • 973-225-3632
• 856-225-7219                         • Fax: 908-782-4068             • Fax: 973-754-1920
• Fax: 856-756-2213
                                       Mercer County Clerk             Salem County Clerk
Cape May County Clerk
PO Box 5000
                                       PO Box 8068
                                       Trenton, NJ 08650-0068
                                                                       PO Box 18
                                                                       Salem, NJ 08079-1913
                                                                                                    Mail the Civilian
Cape May Courthouse, NJ 08210-5000     • 609-989-6494                  • 856-935-7510, ext. 8208     Absentee Ballot
• 609-465-1013                         • Fax: 609-989-1111             • Fax: 856-935-8882
• Fax: 609-465-8625                                                                                     form to the
                                       Middlesex County Clerk          Somerset County Clerk
Cumberland County Clerk                PO Box 1110                     PO Box 3000                    County Clerks
PO Box 716
Bridgeton, NJ 08302-2665
                                       New Brunswick, NJ 08901-1110
                                       • 732-745-3827
                                                                       Somerville, NJ 08876-1262
                                                                       • 908-231-7013
                                                                                                   office in the county
• 856-451-8000, Ext. 211
• Fax: 856-455-1410
                                       • Fax: 732-745-2170             • Fax: 908-253-8853          where you reside.