Clear Form
State of Michigan Voter Registration Application
and Michigan Driver License /Personal Identification Card Address Change Form
1
Are you a citizen of the United States of America?
Yes
No
a n s w e r
Will you be 18 years of age on or before election day?
Yes
No
If you responded No to either of these questions, do NOT complete this form.
2
complete application
Last Name
First Name
Middle Name
Address where you live — house number and stree t/road
Apt. No./ Lot No.
City
Zip Code
Telephone optional
MI
If you do not have a house or street address, describe location where you live — cross streets or roads, landmarks, etc.
City or
Township where you live
County where you live
School District if known
Mailing Address if different
For use on Driver License/Personal ID and Voter Registration
For use on Voter Registration only
Date of Birth
Male
Female
ID Number check applicable box and provide appropriate number
I have a state issued driver license or personal ID card #
State
I do not have a state issued driver license or personal ID card. The last four digits of my Social Security Number are
I do not have a state issued driver license, a state issued personal ID card or a Social Security Number.
An ID number will be assigned to you for voter registration purposes.
Are you still registered to vote at your last address?
Yes
No
Don’t Know If “Yes” or “Don‘t Know” enter previous address
Previous Street Address
City or
Township of
County
State
Zip Code
Registered under name of if different than above
3
read, sign and date
X
I certify that:
Signature of Applicant
Date
–
I am a citizen of the United States.
–
X
I am a resident of the State of Michigan and will be
at least a 30-day resident of my city or township by
Signature of Applicant
Date
election day.
–
I will be at least 18 years of age by election day.
–
I authorize cancellation of any previous registration.
–
The information I have provided is true to the best
Sign and date both spaces provided above.
of my knowledge under penalty of perjury. If I have
provided false information, I may be subject to a fine
or imprisonment or both under federal or state laws.
BEFOR E MA ILING, REMO VE TAPE AND FOLD IN HALF TO SEAL CLOSED.
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