Haines Borough Absentee by Fax or EMail Application
1. Last Name First Name M.I. Suffix (Sr., Jr., III) For Office Use Only
VN_____________
Precinct 33-______
Sent____________
2. Name Previously Registered:
________________
3. Haines Borough, Alaska Residence Address – (Do not use P.O., PSC, HC, or RR Box) Date/Time Received
(Physical Location in Haines)
4. Phone or Email Where You May Be Contacted
(If out of country, please provide country phone code)
5. FAX or EMAIL my Ballot to: 6. Identifier (You MUST provide at least one):
Alaska Voter No.: __________________________
Social Security No.*: ________________________
Date of Birth*: _____________________________
7. Voter Certification: I certify under penalty of perjury, that: I am not requesting a ballot from any other state, and I
am not voting in any other manner in this election. I also certify that I am a U.S. citizen, and at least 18 years of age.
I further certify that I have not been convicted of a felony (unless unconditionally discharged). I am not registered to
vote in any other state.
WARNING: If you provide false information on this application, you can be convicted of
a misdemeanor.
I understand that by using fax or email transmission to return my marked ballot, I am voluntarily
waiving a portion of my right to a secret ballot to the extent necessary to process my ballot, but
expect that my vote will be held as confidential as possible.
I hereby request that an absentee ballot be faxed or emailed to me at the above number or address for:
(please mark one)
ALL _________ (year) Haines Borough MUNICIPAL* elections --or—
Only October Municipal General Election held in year _________
*(Please note that this form does NOT cover State elections. You must contact the State directly to make absentee voting arrangements.)
SIGNATURE: ______________________________________ DATE: _________________
ABSENTEE BY FAX or EMAIL APPLICATION INSTRUCTIONS
At any borough election, a qualified voter may vote an absentee ballot for any reason.
You must reapply each calendar year. Applications may be submitted anytime after January 1
st
and until 5:00 p.m., Alaska time, the day before a Haines Borough election.
It is the applicant’s responsibility to notify the Clerk’s Office of any fax number or email
changes to ensure successful ballot transmittal.
• Print clearly. Use blue or black ink. Use all capital letters.
• All information on this application is mandatory.
• Haines Borough Address – Must be provided on Line 3: A complete physical address must be included on your application.
Your application will not be processed if you leave the residence address blank or if you provide a P.O. Box, HC No. and Box,
PSC Box, Rural Route No., Commercial Address or Mail Stop Address on line 3 of the application.
• This voting mechanism is provided as a convenience to you and you accept the consequence of technological/transmission
difficulties. The Clerk will acknowledge receipt of both your application and your voted ballot. If you do not receive
confirmation, please follow up with the Clerk’s office to assure receipt of your application and/or voted ballot. If you have
questions or need additional information, contact the Borough Clerk at 907-766-6402.
ABSENTEE VOTING FAX NUMBER (907) 766-2716 or EMAIL afullerton@haines.ak.us
Please remember to SIGN this form.
*SSN and date of birth are kept confidential and are used for identification only.
click to sign
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