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2. Covered Facility Type*
   -- Select One --HospitalNursing HomeClinicAdult Care Home
3. Name of Covered Facility*
5. Type of Assistance Requested*

   1. Assistance with absentee request forms
   2. Assistance with voter registration forms
   3. Assistance with absentee ballots

   Select all that apply

6. Number of Individuals Requiring Services*
8. Your Name*
10. Your Phone Number*
11. Your Email Address
13. Requested Date of Event*
    Requested Date of Event
15. Event Address*
17. City*
18. State
19. Zip Code
21. Is internet connectivity available at the facility?*

    1. Yes
    2. No
23. Please provide any other details or questions about this request.
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field