(a) Any person who is registered and otherwise qualified to vote and who is physically disabled and unable to vote in person at the polls in an election may apply to the official designated to supervise and conduct absentee voting for placement on the special absentee voting list.
(b) Any person who is registered and otherwise qualified to vote and who is participating in the Address Confidentiality Program, as established by 48-28A-103 of this code, may apply to the program manager within the office of the Secretary of State for placement on the special absentee voting list. The program manager will notify the designated county contact to coordinate the provision of an absentee ballot to the program participant.
(c) The application is to be on a form prescribed by the Secretary of State which is to include:
(1) The voters name and signature;