Duchesne County Primary Ballot Request Form

Name: (Please Print)

Last

First

Middle

Voter’s Residence Address:

Street (primary physical residence- no P.O. Box)

Apt.#

City

State

Zip Code

Mailing Address (if P.O. Box or different from above)

Apt.#

City

State

Zip Code

Voter’s Phone number:

Voter’s Email Address (optional):

Which Ballot Would you like to receive for the Primary Election?

Democratic	Change my affiliation to Democratic (optional)
Independent American	Change my affiliation to Independent American (optional)
United Utah	Change my affiliation to United Utah (optional)
Utah Forward	Change my affiliation to Utah Forward (optional)

Signature

Today’s Date