GEORGIA VOTER TRANSPORTATION REQUEST
Current Date Election Date :12/05/2017
Last Name * First Name *
Gender *        
Address * Unit
Date Of Birth *  /  /    MM/DD/YY
Zip Code * Number In Party *
Home Phone     Mobile Phone    
State * County *
Transport Request Date From Time : To Time :
Special Needs Please indicate wheelchair type (manual or motorized), if voter uses a cane or the nature of any other disability, including sight.


 


Developed by Richard Rose, CPA1561 Virginia Ave| Suite 208A | College Park, GA 30337 | 404-768-3888 in cooperation with The Coalition for the Peoples' Agenda.  Hosted by Net One Stop.