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2. Facility Name*
4. Street Address*
6. City*
7. State*
8. Zip Code*
10. Contact's Name*
12. Contact's Phone*
13. Contact's Email*
15. Our initial visit.

    It is preferred that everyone who wishes to vote is registered before our initial visit.  
    However, if there are residents that need registering, we will assist them at the initial visit.  Our main goal at the initial visit is to help residents complete their absentee ballot request form.  

17. Estimated number of residents that will need assistance.*
19. We will contact you within 48 hours to discuss the visit. When we call, we will need you to give us 3 potential visit dates and times within the next 2 weeks. You must be flexible in your dates and times as we have limited volunteers that can visit facilities.
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

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