APPLICATION FOR PERMANENT VOTE BY MAIL STATUS

APPLICATION FOR PERMANENT VOTE BY MAIL STATUS
Dear Registrar-Recorder/County Clerk:
I am currently a registered voter in Los Angeles County and am applying for Permanent Vote By Mail status.
NAME: (PRINT) _________________________________________________________________________
DATE OF BIRTH:_________________________________________________________________________
REGISTERED ADDRESS: __________________________________________________________________
CITY: ______________________________________________________ ZIP CODE:___________________
SIGNATURE AS REGISTERED �____________________________________________________________
TELEPHONE NUMBER: (
DATE: ______________________
)____________________
Address where ballot will be mailed (if different from registered address)
ADDRESS: (PRINT) _____________________________________________________________________
CITY: ____________________________________________________ ZIP CODE: ___________________
OFFICE USE ONLY
INPUT DATE
INTL
NOTIFICATION DATE
INTL
VID #
Registrar-Recorder/County Clerk 12400 Imperial Hwy., Norwalk, Ca 90650 USA Rev. 1/08
下記の申請書見本を参考にして永続的郵送による投票の申請書に記入してください。
永続的郵送による投票の申請は上の英語の申請書に記入してください。
永続的郵送による投票申請書
APPLICATION FOR
PERMANENT VOTE BY MAIL STATUS
公認記録係/郡書記さま：
Dear Registrar-Recorder/County Clerk:
私は現在、ロサンゼルス郡の登録有権者であり、永続的郵送による投票者資格を申請いたします。
I am currently a registered voter in Los Angeles County and am applying for Permanent Vote By Mail status.
氏名:
___________________________________________________________________________
NAME:（活字体で記入）
(PRINT)___________________________________________________________________________
生年月日:
______________________________________________________________________________________
DATE OF BIRTH:___________________________________________________________________________
登録住所:
______________________________________________________________________________________
REGISTERED
ADDRESS:____________________________________________________________________
CITY:______________________________________________________ZIPCODE:______________________
市:
_____________________________________________________________ 郵便番号: _____________________
登録済みの署名
__________________________________________________________________________________
SIGNATURE ASXREGISTERED�______________________________________________________________
日付:
電話番号:
(
) ___________________
(
)____________________
DATE: ______________________
TELEPHONE NUMBER:
投票用紙の郵送先住所（登録済み住所と異なる場合）
Address where ballot will be mailed (if different from registered address)
住所: （活字体で記入） ____________________________________________________________________________
ADDRESS: (PRINT)_________________________________________________________________________
市: _____________________________________________________________ 郵便番号: _____________________
CITY: ____________________________________________________ ZIP CODE: ______________________
事務局使用欄
OFFICE USE ONLY
INPUT DATE
INTL
NOTIFICATION DATE
INTL
VID #
Registrar-Recorder/County Clerk 12400 Imperial Hwy., Norwalk, Ca 90650 USA
Rev. 1/08
JAPANESE