Dmv 002 - Driver'S License Or Identification Card Application Page 3

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Application No

SECRETARY OF STATE

STATE OF NEVADA

V O T E R RE G I S T R AT I O N A P PL I C AT I O N

If you decline to register to vote, that fact will remain confidential and will be used only for voter registration purposes. If you choose to register to vote, the office at which you

submitted a voter registration application will remain confidential and will be used only for voter registration purposes.

BOXES 1, 2 AND 7 MUST BE COMPLETED TO REGISTER TO VOTE. This signature box is only for voter registration purposes.

BOX 3 - DO NOT WRITE IN THIS BOX. The DMV will electronically print your address and other required information that you entered on page 1 of this application.

BOX 6 - PARTY REGISTRATION. Mark your choice of a qualified party, “Nonpartisan” or “Other.” If you mark “Other,” you may print the name of an unlisted political party. If you register with a

minor political party or as a nonpartisan, you will receive a nonpartisan ballot for the Primary Election.

BOX 9 - ASSISTING IN THE COMPLETION OF THIS FORM. If you are assisting a person to register to vote, you must complete Box 9. FAILURE TO DO SO IS A FELONY.

CHECK THIS BOX TO RECEIVE A SAMPLE BALLOT IN LARGER TYPE

WARNING: GIVING FALSE INFORMATION IS A FELONY AND INCLUDES A CIVIL PENALTY OF UP TO $20,000

USE BLACK INK — PLEASE PRINT CLEARLY

Check boxes that apply and complete items 4-9

Are you a citizen of the United States of America?

Yes



New Registration

Party Affiliation Change

Will you be 18 years of age or over on or before Election Day?

Yes



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

Name Change

Address Change



form.

DO NOT WRITE

IN THIS BOX

Telephone No. (Optional)

E-mail Address (Optional)

Party Registration—Check Only One Box

“I swear or affirm • I am a U.S. citizen • I will be at least 18 years old by the date of the next election

• I will have continuously resided in Nevada at least 30 days in my county and at least 10 days in my precinct

 Democratic Party

before the next election • The present address listed herein is my sole legal place of residence and I claim no

other place as my legal residence • I am not laboring under any felony conviction or other loss of civil rights

 Independent American Party

that would make it unlawful for me to vote. I declare under penalty of perjury that the foregoing is true and

correct.”

SIGNATURE OF APPLICANT (

REQUIRED)

DATE (REQUIRED)

 Libertarian Party

This signature box is only for Voter Registration Purposes

 Nonpartisan (no party affiliation)

/ _ / ___

 Republican Party

(MM / DD / YYYY)

 Other – Write In Below

Your name and residence address where you were last registered to vote (Name Used, Street, Apt. #, City, State & Zip Code of Former Residence)

Important! If you are assisting a person to register to vote and you are not a field registrar appointed by a County Clerk/Registrar or an employee of a

voter registration agency, you MUST complete the following. Your signature is required. Failure to do so is a felony.

Name

Mailing Address

City/State/Zip Code

Signature