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2. First Name*
3. Last Name*
4. Year of Birth*
6. Address*
7. CITY/STATE/ZIP
   Fraser, MI 48026
11. Would you like all elections mail to be sent to an alternate address?*
    -- Select One --YesNo
12. Alternate Address
    Street #/ City/ State/ Zip Code
14. How can we contact you?*
    -- Select One --PhoneEmailMail Only

    This information is for city use only.
15. Contact Information*
19. Signature*
    Please type in your first and last name to confirm that you are requesting to be placed on the City of Fraser's Permanent Absentee List.
20. Today's Date*
    Today's Date
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field