| 1A |
Student attending college or university outside of locality of residence in Virginia |
Name of college or university |
| 1B |
Spouse of student attending college or university outside locality of residence in Virginia |
Name of college or university |
| 1C |
Business outside County/City of residence on Election Day |
Name of employer or business |
| 1D |
Personal business or vacation outside County/City of residence on Election Day |
Place of travel (VA county/city or state or country) |
| 1E |
I am working and commuting to/from home for 11 or more hours between 6:00 AM and 7:00 PM on Election Day |
Name of employer or businessand Election Day hours of working and commuting (AM to PM) |
| 1F |
I am a first responder (member of law enforcement, fire fighter, emergency technician, search and rescue) |
Not required |
| 2A |
My disability or illness |
Not required |
| 2B |
I am primarily and personally responsible for the care of a disabled/ill family member confined at home |
Family Relationship |
| 2C |
My pregnancy |
Not required |
| 3A |
Confined, awaiting trial |
Name of institution |
| 3B |
Confined, convicted of a misdemeanor |
Name of institution |
| 4A |
An electoral board member, registrar, officer of election, or custodian of voting equipment |
Not required |
| 5A |
I have a religious obligation |
Not required |
| 6A |
Active Duty Merchant Marine or Armed Forces |
Branch of service |
| 6B |
Spouse or dependent living with a member of 6A |
Branch of service |
| 6C |
Temporarily residing outside of US |
Enter your last date of residency at your Virginia voting residence only if you have given up that address permanently or have no intent to return |
| 6D |
Temporarily residing outside of US for employment or spouse or dependent residing with employee |
Name of business or employer |
| 7A |
Requesting a ballot for presidential and vice-presidential electors only
(Ballots for other offices/issues will not be sent) |
New state of residence and date moved from Virginia. Only eligible if you moved less than 30 days before the presidential election. |
| 8A |
Authorized representative of candidate or party serving inside the polling place |
Not required |
