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1.     NAME:______________________________________________________________________________________________

First                                        Middle                                                         Last

 

2.     ADDRESS:___________________________________________________________________________________________

 

3.     BALLOT REQUESTED FOR THE GENERAL ELECTION TO BE HELD NOVEMBER 4, 2008

 

4.        DATE OF BIRTH:_____________________________________________________________

 

5. TELEPHONE:___________________________________________________(Required to determine ballot type)

 

6.     _________________________________________________________              ____________________________________

                                signature                                                                                                               Date

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