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Permanent Absentee Voter List Registration

2. Permanent Absentee Voter List Registration
   By completing the Permanent Absentee Voter List Registration Form, you are requesting that you receive an APPLICATION FOR ABSENTEE VOTER’S BALLOT for every election and you acknowledge that an application must be completed, signed and returned to the City Clerk prior to receiving an election ballot. You will remain on the Permanent Absentee Voter List for every election conducted in the City of Madison Heights unless you notify the Clerk’s office you wish to be removed. Signing up for this list does not prevent you from the option of voting in-person if you choose not to vote by absentee ballot for any given election.
4. First Name *
5. Last Name *
6. Date of Birth *
7. Date *
   Date
9. Street Number*
10. Street Name *
12. City
13. State
14. Zip Code
16. Agreement

    1. by checking this box, I am verifying that I am a qualified and registered elector at the residence, house, apartment or dwelling of the address listed.
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field