Form No. 11-A Prescribed by the Secretary of State (06-14)
PLEASE PRINT OR TYPE (See Instructions at Bottom of Page)
R.C. 3509.03
Voter’s Name
Home Address
City, Village, Office
Send Ballot to: (if different from home address)
care of/PO Box
City ZIP
You must provide your birth date (MM/DD/YYYY):
and ONE of the following:
(begins with two letters followed by six numbers)
, or
(last four digits of SSN)
, or
Your Ohio driver’s license number
The last four digits of your Social Security number
Copy of a current and valid photo identification, a military identification, or a current (within the last 12 months) utility bill,
bank statement, government check, paycheck, or other government document (other than a notice of voter registration
mailed by a board of elections) that shows your name and current address.
I wish to vote in the election to be held on
Check ONLY one election (A separate application must be completed for each election):
(If you checked primary election, select the type of ballot):
(Name of political party)
1. Primary Election
2. General Election
3. Special Election
Party Issues Only
I wish to have a ballot mailed to me at the address listed above. I understand that if a ballot is mailed to me and I change my
mind and appear at my polling place to vote on Election Day, I will be required to vote a provisional ballot that can not be
counted until at least 11 days after the election.
I hereby declare, under penalty of election falsification, I am a qualified elector and the statements above are true to the best
of my knowledge and belief. I understand that if I do not provide the requested information, my application cannot be
Signature of Voter
Voluntary: To assist the board of elections in contacting you in a timely manner if your application is incomplete:
Your daytime telephone number
Your e-mail address
Chapter 3509 of the Revised Code of Ohio
1. An application by mail must be received by your county board of elections by noon on the third day before the election. Applications for
persons who are hospitalized or for persons whose minor child is hospitalized due to an accident or unforeseeable medical emergency
(Form 11-B) will be accepted until 3 p.m. on Election Day.
2. If you return your ballot by mail, it must be received by your board of elections by 7:30 p.m. on Election Day or postmarked* no later than the
day before Election Day and received by your county board of elections no later than 10 days after the election. If you return your ballot in
person, or if a near relative delivers it to the board for you, it must be received by your county board of elections no later than the close of polls
on Election Day. If you are a member of the uniformed services or a voter outside of the United States on Election Day, the ballot must be
submitted for mailing not later than 12:01 a.m. on the date of the election and received by the board no later than 10 days after Election Day.
* Postmarked does not include a date marked by a postage evidence system such as a postage meter.
date of election (mm/dd/yyyy)
Date Signed