Instructions:  Print and complete this application and mail or fax it to the Washington County Board of  Elections

WASHINGTON COUNTY BOARD OF ELECTIONS

APPLICATION FOR LISTING OF REGISTERED VOTERS
DEADLINE TO REQUEST FOR PRESIDENTIAL GENERAL ELECTION

October 14, 2008

35 W. Washington Street
Hagerstown, MD 21740
Telephone: 240-313-2050
Fax: 240-313-2051
MD Relay Service: 240-313-2050

Applicant's Name:_________________________________________________________ Date: ______

Applicant's Residence Address:__________________________________________________________

Registered Voter In: ____________________________________ County District _____ Precinct ______

Telephone Numbers: Home ____________________                       Business _______________________

Delivery Address (If Applicable)__________________________________________________________

If the list is being purchased on behalf of a corporation or other business entity, give name and address of entity:  ___________________________________________________________________________________

Intended use of data:_________________________________________________________________

PLEASE READ THIS STATEMENT BEFORE SIGNING: Under the penalty of perjury, I hereby declare, as required by the Registration and Election Laws of Maryland, that I do not intend to and I will not use the list of registered voters for which I am applying for purposes of commercial solicitation or for any other purpose not related to the electoral process, and that I will not knowingly allow the list to be used by any other person or entity for purposes of commercial solicitation or for any other purpose not related to the electoral process.  I am aware that if I or any other person who has a registration list under his or her control knowingly allows any part of that list to be used for commercial solicitation or for any other purpose that is not related to the electoral process, that individual is guilty of a misdemeanor and, on conviction, subject to imprisonment for not less than 30 days or more than 6 months, to a fine of up to $250, or to both imprisonment and fine.

Applicant's signature ___________________________________________________________________ 

I, ____________________________, agree to pay the balance due, prior to receipt of the requested output.    (Print applicant's name) 

Disclaimer:  The Washington County Board of Elections does not guarantee your computer program will be compatible with all software programs.  The applicant will utilize his/her own software program database in order to import this information to his/her database.

GENERAL INFORMATION

QUALIFICATIONS: To apply for a voter registration list the applicant must be a registered voter in Maryland and must sign a statement, under penalty of perjury, that the list is not intended to be used for purposes of commercial solicitation or any other purpose not related to the electoral process. (Election Law Article, 3-506, Annotated Code of Maryland and COMAR 33.03.02.03A and 33.03.02.04). The applicant's registration will be verified before processing of the request.

APPLICATION DEADLINE: Before any election, neither the State Administrator nor any election director may respond to an application for a voter registration list unless the application was filed on or before the registration deadline. Applications received after that date shall be returned. (COMAR 33,03.02.05B)

SUPPLEMENTAL LIST: A request for a supplemental list must be made at the time of this initial request.  The initial list will be prepared now, and the supplemental list will be prepared after the registration deadline and will consist of new registrations only.  The applicant also agrees to pay the additional costs for the supplemental list (if applicable) prior to receipt of the output. 

TURN AROUND TIME: Requests made near the closing of the books will be prepared within 10 working days after the registration deadline.

FILE CONTENTS: Each file will contain the following fields: registrant's full name, residence address, mailing address (if applicable), registration date, date of birth, gender, party affiliation, district/precinct, registrant ID number, status and voter history (when applicable).

DEPOSIT: A deposit in the amount specified above, in the form of cash, certified check, personal or campaign checks, or money order must accompany this application. The applicant also agrees to pay the balance due (if applicable) prior to receipt of the requested output. 
Make checks payable to: Washington County Treasurer

MINIMUM CHARGE: A minimum fee of $10.00 will be imposed on requests for CD ROMS containing partial county data.

DELIVERY INSTRUCTIONS: Output may either be picked up from the Election Board or mailed to applicant. However, if mailed the applicant is responsible for shipping costs and must provide an account number for billing purposes.

RETURN CHECK POLICY: All returned checks will be assessed a fee of $25.00