Application for Mail-In Ballot
Fill out this form to generate your completed mail-in ballot application. Print the completed application, sign, date, and bring it with you to your appointment.
Your name
Please type your name exactly as you registered to vote.
Name
*
First Name
Middle Name or Initial
Last Name
Suffix
Jr
Sr
II
Ill
IV
About you
Phone and email are optional and used if information is missing on this form.
Birth date
*
/
Month
/
Day
Year
Date Picker Icon
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Your address
Please print your address exactly as you registered to vote.
Address (Not P.O. Box)
*
Street Address
Apt Number
City
State / Province
Postal / Zip Code
County
*
Centre
I have lived at this address since
-
Month
-
Day
Year
Date
Identification
If you have a PennDOT number, you must use it. If not, please provide the last four digits of your Social Security number. You must provide either your SSN or your PennDOT number to proceed.
PA driver's license or PennDOT ID card number
*
Last four digits of your Social Security number
*
Annual mail-in request
If you indicate you would like to be added to the annual mail-in ballot request list, you will receive an application to renew your request for mail-in ballot each year. Once your application is approved, you will automatically receive ballots for the remainder of the year and you do not need to submit an application for each election.
If you would like to apply to receive mail-in ballots for the remainder of this year and if you would like to automatically receive an annual application for mail-in ballots each year, please indicate below.
I would like to receive mail-in ballots this year and receive annual applications for mail-in ballots each year.
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Almost Done
Your mail-in ballot application is nearly ready to print out. You can preview your mail-in ballot application below. Then once you are ready, click "Generate Your Mail-In Ballot Application" to finalize your form and send it back to you. You MUST print, sign, date, and bring your completed application with you to your appointment at the Bryce Jordan Center. By clicking "Generate Your Mail-in Ballot Application", the Satellite Elections Office will also receive a secure electronic copy of your application.
Preview PDF
Generate Your Mail-In Ballot Application
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