Application For Addition To The Checklist printable pdf download

VERMONT Application for Addition to the Checklist (VT VOTER REGISTRATION FORM)

17 V.S.A. § 2145

(Please print clearly, use ballpoint pen, and bear down hard.)

I, ______________________________________________________________

apply to have my name

)

(Last Name)

(First Name)

(Middle Initial

added to the checklist of the Town/City of ______________________________________.

By checking the boxes below, I swear or affirm that these are true statements:

⁭ Yes

⁭ No

Are you a citizen of the United States?

Yes

Will you be eighteen years of age or older on or before the day of election?

Yes

Are you a resident of Vermont?

If you checked "No" in response to any of the three questions above, DO NOT complete this form. You are not qualified

to vote in Vermont

. Contact the Office of the Secretary of State, Elections Division, for more information at (800) 439-8683.

I was born on ________________________ at _________________________________, ___________________________

(Date)

(Town or City)

(State)

My principal dwelling is located at:______________________________________________________________________

(E911 street address including number or exact physical location, if no E911 address)

Mailing Address: ___________________________________________________________ Tel. #: ___________________

Email:__________________________________________

(optional - for contact purposes only).

By registering to vote in the above named town in Vermont, I authorize my name to be removed from the list of registered voters in any

previous place where I was registered to vote.

The last address I was registered to vote at: __________________________________________________________.

(Physical location – include number, street, town, state and zip code)

I was previously registered with a different last name of: _______________________________________________________.

My VT Driver’s License or Personal I.D. # (PID#) issued by VT DMV is__________________.

This # is REQUIRED.

IF you do not have a VT Driver’s License or PID# issued by VT DMV enter the last 4 digits of your Social Security

Number:________ . If you do not have a VT PID#, or SSN, please contact the Office of the Secretary of State, Elections Division,

(800)439-8683.

By checking this box I swear or affirm that:

I have taken the Voter's Oath

I meet all of the eligibility requirements to vote in this municipality

. I hereby swear, or affirm, under penalty of perjury

and other potential federal or state criminal penalties of up to a $10,000 fine, or imprisonment for not more than fifteen years, or

both, that the statements made by me in this application are true

. (17 V.S.A. § 2145(f); 17 V.S.A. § 2011; 42 U.S.C. § 1973gg-10).

____________________________

______________________________________________

Today’s Date

Applicant’s Signature

First time Registrants in Vermont must take the voter’s oath.

You must be 18 to take the oath:

“You solemnly swear or affirm that whenever you give your vote or

VOTER'S OATH (Vermont Constitution, Chapter II, Section 42):

suffrage, touching any matter that concerns the State of Vermont, you will do it so as in your conscience you shall judge will

most conduce to the best good of the same, as established by the Constitution, without fear or favor of any person.”

The person administering the oath or the applicant must sign the certification below.

I hereby certify that on the___ day of ________________, 20___, ⁭ I administered the Voter’s Oath to the applicant, or

⁭ I, the applicant, took the oath myself. Any person over 18 or the applicant can sign to attest that the oath was taken.

(Check box above & sign.)

Attestation:______________________________________

Signature of Attester

if you are registering to vote for the 1

time in Vermont, AND you are mailing this application to your town clerk

ONLY

individually, you must submit a photocopy of one of the following: current & valid photo identification OR bank statement, utility bill, or

government document with your name and current address. (Do not submit I.D. if you have been previously registered in VT, if this

form is submitted as part of a voter registration drive, or if you return this form to the clerk’s office in person.)

FOR OFFICIAL USE:

The Town Clerk OR the BCA has reviewed the application AND the applicant

was added to the checklist.

The applicant’s usual polling place is: _____________________________________________. OR the applicant

was rejected and

NOT added to the checklist. The reason(s) for rejection are: _____________________________________.

Signature of town clerk: ____________________________.

Date Entered on Checklist: _____________ Date Notification Sent to Voter:_____________ Date Approved: ____________

. Contact your Town Clerk to make sure your application has been received.

KEEP THE PINK COPY OF THIS APPLICATION FORM

Bring pink copy to the polls when you go to vote. This is proof you have submitted an application before the deadline for registration.

[SOS-VR-5/12/2014]

Application For Addition To The Checklist

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