Wyoming Voter Registration Form (Page 2 of 2) in pdf

Wyoming Voter Registration Application & Change Form

VR # ___________________ County # ________

District _________ Precinct _________ Split __________

New Voter Application

Change to Current Registration

School __________ House __________ Senate_________

Municipality __________ Ward ____________

Name Change

1. Name and Date of Birth

Legal

Suffix

Last Name

First Name

Middle Name

Date

County

of Birth

Resident Since

2. Wyoming Driver’s License

You must provide this number if you hold a valid Wyoming Driver’s License

Valid Wyoming Driver’s License Number:

Mark here only if you do not have a valid Wyoming Driver’s License and go to step 2a.

2a. Social Security Number

Last four digits are required if you do not have a valid Wyoming Driver’s License

Social Security Number

Mark here only if you do not have a valid Wyoming Driver’s License or a Social Security Number.

3. Personal Information * Denotes optional information

Gender*

Male

Wyoming Residence Address (No P.O. Box Numbers)

City

Zip

Female

Address Where You

Mailing

State

Zip

Get Your Mail

City

Phone*

Are you interested in being an Election Judge?*

Yes

E-mail*

Do you need assistance to vote? *

Yes

4. Political Party

Choose one of the following

Republican

Democratic

Libertarian

Constitution

Unaffiliated

5. Changes to Current Wyoming Voter Registration

Former Wyoming Residence

City

WY County

State

Zip

Street Address

Wyoming

Former

Suffix

Last Name

First Name

Middle Name

5a. Withdrawal of Voter Registration from Another State

Residence address in prior State

Street Address

City

County

State

Zip

6. Registration Oath and Acknowledgement

Required on all applications.

I do solemnly swear (or affirm) that I am a citizen of the United States; that I am a bona fide resident of the state of Wyoming and this county; that if registered in

another county or state, I hereby request that my registration be withdrawn; that I will be at least eighteen (18) years of age on or before the next election; that I

am not currently adjudicated a mentally incompetent person; that I have not been convicted of a felony, or if I have been convicted of a felony, I have had my civil

or voting rights restored by a competent authority; and that the voter registration information contained herein is true and accurate to my best knowledge and

belief.

Sign your legal name

in full

Proof of Identification Shown

Type of Identification

Subscribed and affirmed or sworn to before me by

__________________________________________________________ (name of applicant) on ____________________________ (application date)

Title

Signature & Title of Registry Agent or

person authorized to administer oaths

3/2014