America360 Absentee Request Application

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Paid for by America 360 Committee Michael Adams, Treasurer 801 Pennsylvania Ave NW, Suite 610 Washington, DC 20004

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Massachusetts Absentee Ballot Application November 6, 2012 General Election __________________________________ Full Name __________________________________ Address

Absentee Application I am a registered voter at the address included on this card. I hereby request an absentee ballot for the reason shown below. Please mail my ballot to the address included on this card.

Massachusetts Absentee Ballot Application November 6, 2012 General Election __________________________________ Full Name __________________________________ Address

Absentee Application I am a registered voter at the address included on this card. I hereby request an absentee ballot for the reason shown below. Please mail my ballot to the address included on this card.

______________ ______ ___________ City State Zip

I will be absent from my city or town on election day.

______________ ______ ___________ City State Zip

I will be absent from my city or town on election day.

( ) -­ ___/___/_____ Telephone

Date of Birth

I have a physical disability that prevents my voting at the polling place.

( ) -­ ___/___/_____ Telephone

Date of Birth

I have a physical disability that prevents my voting at the polling place.

__________________________________ Ward/Precinct (if known)

I cannot vote at the polls due to my religious beliefs.

__________________________________ Ward/Precinct (if known)

I cannot vote at the polls due to my religious beliefs.

____________________________ Signature

_______________ Date

____________________________ Signature

_______________ Date