USVI Public Records

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ELECTION SYSTEM OF THE VIRGIN ISLANDS Sunny Isle Shopping Center, Christiansted, St. Croix, V.I. (340) 773-1021 9200 Lockhart Garden Shopping, St. Thomas, V.I. 00804 (340) 774-3107 Website: www.vivote.gov ABSENTEE BALLOT APPLICATION APPLICATION INFORMATION TYPE OR PRINT ONLY Name: ______________________________________________________________ Sex: Male ___ Female ____ (As listed on the voter Registration Card) Last Four Digits of SS Number: ___________ Date of Birth: _________ Place of Birth: __________________ Party Affiliation: (Select only one) Democrat ___Republican __ ICM- Independent Movement ___ No Party ___ Local Physical Address (No. and Street) ___________________________________________________________________________________ (As listed on registration card) Local Mailing Address: ___________________________________________________________________________________ Telephone: ______________/Work _____________/Home _________________/Cellular _____________/Fax Email Address: ____________________________________ MAIL ABSENTEE BALLOT TO: (Complete mailing address where you want ballot to be mailed) METHOD OF PREFERENCE IN RECEIVING APPLICATION OR BALLOT: WALK-IN___ MAIL-IN____ E-Mail (MILITARY ONLY) _____ REASON FOR ABSENTEE BALLOT (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 ____ f. 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 ____ 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 ____ 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 ____ i. Religious grounds I REQUEST AN ABSENTEE BALLOT FOR THE FOLLOWING ELECTION(S): ____ PRIMARY ____GENERAL ____SPECIAL _____ALL Elections conducted in the calendar year __________________________________________ ______________ SIGNATURE OF VOTER or Voter Representative DATE I swear or affirm to the self-administered oath, under penalty of perjury 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 or 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(s) D. That I meet all the qualifications of a Virgin Islands elector. E. The information on this form is true and correct. ________________________________________ ____________ SIGNATURE OF ELECTOR/VOTER DATE ____________________________________________________________________________ FOR OFFICIAL USE ONLY -- Registered Voter YES NO Ballot Issued ____ ____ Ballot Returned ____ ____ Application Rejected ____ ____ REASON: ______________________________