Illinois Voter Registration Application
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1ILLINOIS VOTER REGISTRATION APPLICATION
Use block letters only.
Register to vote online at
Are you a citizen of the United States?
Yes
No
If you checked “No” in response to either of
1
these questions, DO NOT complete this form.
Will you be at least 18 years of age on or before the general election?
Yes
No
Jr.
Sr.
II
III
IV
V
Suffix (circle one if applicable)
Last Name
First Name
Middle Name or Initial
2
Previous Name (if changed)
Email Address
Street Address Where You Live
Apartment Number
3
___________
City
State
Zip Code
County
Sex (circle one)
Date of Birth
M
F
Month
Day
Year
Cell Phone Number (or landline)
4
Would you be interested in
serving as an election judge?
Illinois Driver’s License Number or IL State ID number
YES
NO
(If you have neither, list the last four digits of your social security number.)
SIGN OR MARK IN BOX BELOW
Voter Affidavit - Read all the statements and sign on the line below.
I swear or affirm that:
* I am a citizen of the United States.
* I will be at least 18 years old on or before the general election.
* I will have lived in the State of Illinois and in my election precinct at
least 30 days as of the date of the next election.
X _________________________________________
5
* The information I have provided is true to the best of my knowledge
under penalty of perjury. If I have provided false information, then I
may be fined, imprisoned or, if I am not a U.S. Citizen, deported from
or refused entry into the United States.
DATE: ____________________________________________________
If you cannot sign, ask the person who helped you complete this form to print their name, address and telephone number below.
Name _____________________________ Address _______________________________________ Phone Number __________________________
IMPORTANT INFORMATION:
» Federal law requires first-time voters who register by mail to show proof of identification in order to vote. You may be able to
satisfy this requirement by providing your driver’s license number, state ID # or, if you don’t have either of these, the last 4
digits of your social security number on this form. If we are able to verify your identity with one of these numbers, it will
not be necessary for you to show ID in order to vote. If we cannot verify your identity through a valid driver’s license
or social security number, you will need to provide identification before you can vote. Acceptable forms of identification
include: a copy of a current and valid photo ID, or a copy of a current utility bill, bank statement, government check, paycheck,
or other government document that shows your name and address. A copy of your identification can be mailed in an envelope
to us along with this registration form, or can be shown the first time you vote.
» Mail or deliver your completed application to:
Cook County Clerk’s Office
69 W. Washington, Suite 500
Chicago, IL 60602
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