Fillable Voter Registration Application printable pdf download

STATE OF GEORGIA APPLICATION FOR VOTER REGISTRATION

Fill out the bottom half of this application by following these directions. Print clearly and use blue or black ink.

LEGAL NAME. Your full legal name including any suffix such as Sr., Jr., III, is required on this form.

ADDRESS. Provide residential address. This information is required.

MAILING ADDRESS. If mailing address is different from residential address, complete the mailing address section.

PERSONAL INFORMATION. A telephone number is helpful to registration officials if they have a question about your application. Gender

and race are requested and are needed to comply with the Voting Rights Act of 1965, but are not mandated by law.

VOTER IDENTIFICATION NUMBER. Federal law requires you to provide your full GA Drivers License number or GA State issued ID

number. If you do not have a GA Drivers License or GA ID you must provide the last 4 digits of your Social Security number. Providing your

full Social Security number is optional. Your Social Security number will be kept confidential and may be used for comparison with other state

agency databases for voter registration identification purposes. If you do not possess a GA Drivers License or Social Security number please

check the appropriate box and a unique identifier will be provided for you.

OATH. Federal law requires that you answer the citizenship and age questions. Read the oath and sign your name. If you cannot complete this

application unassisted because of physical disability or illiteracy, you must either sign or make your mark on the signature line, and the person

assisting you MUST sign the signature space for person assisting voter.

POLL OFFICER QUESTION. Your willingness to be a poll worker will have no bearing on your application for registration.

NAME/ADDRESS CHANGE. Complete these sections to change the name or address of your current voter registration.

MAP/DIAGRAM: If you live in an area without house numbers and street names, please include a drawing of your location to assist us in

locating your appropriate voting precinct.

10. DELIVERY INSTRUCTIONS: Verify that you have completed and signed the application. Enclose a copy of your ID if you are submitting

this form by mail and registering for the first time in Georgia. Fold the application in half, remove the tape at the top, and press the edges

together. The application is ready for you to mail (postage is prepaid) or deliver to your county voter registration office.

11.

You are NOT officially registered to vote until this application is approved. You should receive a voter precinct card in the mail. If you do

not receive this acknowledgement within two to four weeks after mailing this form, please contact your county voter registration office. You can

find your poll location and other election information on the Secretary of State’s website at

REQUIREMENT: If you are submitting this form by mail and you are registering for the first time in Georgia, enclose a copy of one of the

following with your application: A copy of a current and valid photo ID, a copy of a current utility bill, bank statement, government check, paycheck, or

other government document that shows your name and address. Those who are entitled to vote by absentee ballot under the Uniform and Overseas Citizens

Absentee Voting Act are exempt from this requirement.

Place copy of

Trim copy of

ID in pocket

ID to size

OFFICE USE ONLY

CHANGE OF ADDRESS

DISTRICT COMBO

COUNTY PRECINCT

MUNICIPAL PRECINCT

DDS APLICATION NO.

REGISTRATION NO.

CHANGE OF NAME

OTHER_

__________________________

LAST NAME

FIRST NAME

MIDDLE OR MAIDEN NAME

SUFFIX

Jr.

Sr.

III

STATE

APT. NO.

CITY

ZIP CODE

RESIDENCE ADDRESS: House No. and street name

COUNTY

GA.

MAILING ADDRESS (If different from residence address): Post-office box or route

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

DATE OF BIRTH: MM/DD/YYYY GENDER

RACE/ ETHNICITY:

TELEPHONE NUMBER

GENDER

DATE OF BIRTH: MM/DD/YYYY

RACE/ ETHNICITY:

White

Hispanic/Latino

Black

Male

Female

(

)

Asian/Pacific Islander

American Indian

Other________________________________________

VALID GA. DRIVER’S LICENSE OR GA. I.D. NO.

FULL SOCIAL SECURITY NUMBER (OPTIONAL)

Check if you do not have a GA

Last 4 Digits (Required)

If no GA Driver’s License or GA. I.D. No., must

Driver’s License, GA. I.D. No. or

provide last 4 digits of your Social Security

Social Security No.

Number

(Your answer is required under federal law)

I SWEAR OR AFFIRM:

Yes

WARNING: Any person who registers to vote knowing that

Are you a citizen of the United States of America? Check One:

such person does not possess the qualifications required by

Yes

Will you be 18 years of age on or before election day? Check One:

law, who registers under any name other than such person’s

If you checked “No” in response to either of these questions, do not complete this form.

own name, or who knowingly gives false information in

I SWEAR OR AFFIRM THAT:

registering shall be guilty of a felony.

I reside at the address listed above.

O.C.G.A. § 21-2-561

I am eligible to vote in Georgia.

I am not serving a sentence for having been convicted of a felony involving moral turpitude.

I have not been judicially declared to be mentally incompetent.

Signature of person helping illiterate or disabled voter

Date

Signature

May we contac

t you about working as an

Election

CHANGE OF NAME: If you are changing your name, list the name under which you were previously registered:

Military

Last Name

Suffix

First

Middle or Maiden Name

Day poll officer

Active

Yes

Duty?

If you would like

to receive additional infor

mation

CHANGE OF ADDRESS: If you are changing your address or if you were previously registered to vote, list your previous

by email, please provide your e-mail address:

address:

Yes

CITY

COUNTY

STATE

Voter Registration Application

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