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Prefix
First Name
Last Name
Mid Name
Suffix
Mr
Mrs
Miss
Ms
Jr
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II
III
IV
Home Address
Apt #
City
State
Zipcode
AK
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AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
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NV
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OH
OK
OR
PA
RI
SC
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TN
TX
UT
VT
VA
WA
WI
WV
WY
Telephone Number (optional)
Email Address
This information is necessary so that we can properly match you to your elected officials and to assist you in both registering to vote and requesting an absentee ballot.
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