ILLINOIS VOTER REGISTRATION APPLICATION - Jersey County, Illinois
New Registration
Change Address
Change Name
TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK
Are you a citizen of the United States of America?
YES
NO
Will you be 18 years of age on or before the next General Election Day?
YES
NO
If you checked “no” to either of these questions, then do not complete this form.
Last Name
First Name
Middle
Suffix (Jr. Sr. II)
Residence Address
City
State
Zip Code
(House Number, Street Name, Apt)
Mailing Address
City
State
Zip Code
(if different than residence address)
Complete Former Registration Address
Former County
Former Name
Date of Birth: MM/DD/YYYY
Phone Number:
Sex:
M
F
IL Driver’s License or State ID Number
Last 4 Digits of SSN
Voter Affidavit – Read all statements and sign within the box. By signing, I swear or affirm that:
I am a citizen of the United States.
I will be at least 18 years of age on or before the next General
Election Day.
I have lived in the State of Illinois and in my Election precinct
at least 30 days as of the date of the next election.
The information I have provided is true to the best of my
knowledge. I understand that if I provide false information I
may be fined, imprisoned, or if I am not a US Citizen, deported
from or refused entry into the United States.
TODAY’S DATE:_________________________ REGISTRAR INITIALS:______________________