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2. Voter Information

4. Name: As it Appears on Voter Registration*
6. Date of Birth*
   Date of Birth
8. Mailing Address*
10. City*
11. State*
12. Zip Code*
14. Cheverly Ward (1 to 6)*
    -- Select One --123456
16. Phone Number*
17. Email Address*
19. Preferred Contact Methods

    1. Email
    2. Phone Call
    3. Text

    (Check all that apply)

21. I am Registered to Vote in: *

    1. Maryland
    2. Town of Cheverly

    You must be registered to vote to request a mail-in ballot.

    
    

23. Delivery

25. Delivery Instructions:*

    1. Mail to the address above
    2. Mail to a different address
    3. I will pick up my ballot in-person
    4. My ballot will be picked up in-person by a designated agent
27. Designated Different Address to Mail Ballot
29. Name of Designated Agent

31. Signature

    I hereby affirm under penalty of perjury under the laws of Maryland that all of the above statements are true to the best of my knowledge and belief.

33. Sign Here*

    Sign your name to acknowledge that you are the person listed in the name space above at the top of this form. 

35. Date of Signing*
    Date of Signing

37. This form will be submitted automatically to The Cheverly Board of Elections Supervisors.

    This form must be received by close of business on April 28, 2025 in order to obtain a mail-in ballot for the May 5, 2025 election. In-person ballot pick-up must be done by May 2, 2025.

    Warnings: Anyone who willfully signs any false application or oath, or who willfully does any act contrary to the terms and provisions of the Cheverly election laws with intent to cast an illegal vote or to aid another in doing so, or who willfully violates any of the provisions of such laws, or who applies for a ballot under any other name than his/her own, shall, upon conviction, be subject to a fine of $100 or to imprisonment for not more than thirty (30) days or to both, in the discretion of the Court. A mail-in ballot will not be sent unless the applicant is registered to vote in elections for the Town of Cheverly. No voter may vote in person once the voter's mail-in ballot is received and registered by the Cheverly Board of Election Supervisors.

Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field