ATTENTION CLAIBORNE COUNTY ELECTION COMMISSION
I formally "Request an Absentee Ballot" based upon the following information.

1) PRINT NAME AS REGISTERED______________________________________________________________________

2) ADDRESS WHERE YOU LIVE________________________________________________________________________

3) MAIL MY ABSENTEE BALLOT TO THIS ADDRESS_______________________________________________________

4) MY SOCIAL SECURITY # IS___________________________ 5) MY DATE OF BIRTH IS_________________________

6) MY LEGAL REASON FOR VOTING ABSENTEE IS ( CHECK ONE )
	____I will be outside of this county during all hours of early voting and Election Day (must include mailing address
		outside the county)
	____I am enrolled as a full time student or a spouse of a student at an institution inside Tennessee and outside
		the county where I am registered. (must include mailing address outside county)
	____I am a permanent absentee voter and have a doctor statement on file 
	____I am hospitalized, ill, or physically disabled and because of such condition I am unable to appear at my
		polling place for this election.
	____I am a caretaker of a person who is ill or disabled 
	____I am on jury duty in a state or federal court 
	____I am over 60 years of age. 
	____I am a candidate 
	____I am serving as an election official or a member or an employee of the Election Commission on election day.
	____I am observing a religious holiday that prevents me from voting early or election day 
	____I have a Commercial Drivers License (CDL) or spouse of a person possessing a CDL or a Transportation
		Worker Identification Credential (TWIC) & will be out of the county during early voting & Election Day
		& have no specific out-of-county or out-of-state address to receive mail during this time. Enclosed is a copy
		Of my CDL or my spouse’s CDL or my TWIC card. The CDL # is_________________________
	____I reside in a licensed facility, outside the county, providing relatively permanent domiciliary care, i.e.
		Nursing Home (must include mailing address outside county) 
	____I am a voter covered under the Uniformed and Overseas Citizen Absentee Voting Act (must include mailing    
		address outside county even if emailing ballot) Ballot to be sent : ____by mail ____email
		email address:_______________________________________________________________________

7) I WISH TO VOTE IN THE (PLEASE CIRCLE ONE)   

GENERAL ELECTION	REPUBLICAN PRIMARY ELECTION	DEMOCRAT PRIMARY ELECTION	

I swear or affirm, under the penalty of perjury, that all the information on this form is true and correct and that I am eligible to vote in this election.
8) Signature of Voter______________________________________________________________

If the voter is unable to sign their name or make a mark, the person assisting and one witness must also
sign their names and provide their address.

Person assisting_________________________Name of person witnessing_______________________

FORWARD THIS INFORMATION TO:	Claiborne County Election Commission	OR	 Fax to: 423-626-6770
						P.O.Box 343
						Tazewell, TN  37879
						Phone:   423-626-5128
_____   _____   _____   _____   _____   _____   _____   _____   _____   _____   _____  
FOR CLAIBORNE COUNTY ELECTION OFFICE USE:
(Circle One)  This Request has been:	Approved  or  Rejected  on __________by______________________________

Precinct_______District_____ID # ________________Application signature verified on__________by_________________

Ballot Sent__________  Ballot Rcvd__________  Ballot Affidavit Signature verified on _________by_________________