Wisconsin Voter Registration Application

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This form is available in an accessible format, upon request.
Submitted by Mail
Wisconsin Voter Registration Application
(Office Use Only)
SVRS ID #
Confidential Elector ID#
(HINDI - sequential #) (Office Use Only)
(Office Use Only)
Instructions for completing sections 1-12 are on the back of this form. Return this form to your municipal clerk, unless directed
otherwise.
Please use uppercase (CAPITAL) letters only.
Fill in circles as appropriate.
NOTE: If this is a change of address, then upon completion of this application your voting rights will be cancelled at your previous residence.
If you have not voted in WI and are submitting this application by mail, you must also provide a copy of an acceptable proof of residence
Town
New WI Voter
Municipality
Village
Name Change
City
1
WI Address Change
County
I have neither a WI
Wisconsin Driver License/ID Number
Driver License/ ID
-
2
nor a Social
X X X - X X -
Social Security Number - Last Four Digits (only if no license/ID number)
Security Number.
Print your name exactly as it appears on the document, the number of which you provided in Box 2.
).
(Driver License/ID Card or Social Security Card
Last Name
First Name
3
Middle Name
Suffix
Phone #
(e.g. Jr, II, etc.)
Date of Birth
Email Address
(M/D/YYYY))
Residence Address: Street Number & Name
4
Apt. Number
City
State
ZIP + 4
Mailing Address: Street Number & Name
5
Apt. Number
City
State
ZIP + 4
Last Name
First Name
6
Middle Name
Suffix
(e.g. Jr, II, etc.)
Address: Street Number & Name
7
Apt. Number
City
State & Zip + 4
Please answer the following questions by filling in “Yes” or “No”:
If you filled in ‘No” in response to EITHER of these
Yes
No
8
1. Are you a citizen of the United States of America?
questions, do not complete this form.
Yes
No
2. Will you be 18 years of age on or before election day?
I certify that I am a qualified elector, a U.S. citizen, at least 18 years old or will be at least 18 years old at the time of the next election, having
resided at the above residential address for at least 10 days immediately preceding this election, with no present intent to move. I am not
9
currently serving a sentence including probation or parole for a felony conviction, and not otherwise disqualified from voting. I certify that all
statements on this form are true and correct. If I have provided false information I may be subject to fine or imprisonment under State and
Federal laws. If completed on Election Day: I further certify that I have not voted in this election. (Please fill in circle.)
Accommodation needed at poll location (e.g. wheelchair
If you do not have a street number or address, use the map to show where you live.
access):
Mark crossroads
N
Example
Library
„X‟ where you live
10
Woodchuck Road
Use dots for
I am interested in being a poll worker.
landmarks
X
High School
Today‟s Date
(M/D/YYYY)
Signature of
X
11
Official Use Only: Election Day Voter #
Elector
Corroborator/Assistant Signature:
Corroborator / Assistant Address:
Office Use: Proof of residence type
12
Office Use: Proof of Residence #
Official‟s Signature:
SRDs printed name and SRD#:
Ward
Sch. Dist.
Alder
Cty. Supr.
Ct. of App.
Assembly
St. Senate
Congress
EB-131 (SHADED, WITHOUT HASHMARKS) (REV 10/2008)

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