Voter Name:
Residential Address (Street number and name):
Residential Address (City, State, Zip):
Date of Birth, month (MM):
Date of Birth, day (DD):
Date of Birth, year (YYYY):
County (or write "Baltimore City"):
Telephone (xxx-xxx-xxxx):
Print Circulator Signature Date: Check this box only if you are going to sign it today -- you cannot have anyone else sign the blank spots later! If you are going to handwrite anyone else in, uncheck this, write in the signature date, and sign it after all signers are finished.