Arkansas Voter Registration Application Template - 2015
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1
2PLEASE PRINT AND USE BLAck INk To comPLETE
Rev. 12-17-15
ARkANSAS VoTER REgISTRATIoN APPLIcATIoN
Office Use Only
check all that apply:
____ This is a new registration.
____ This is a name change.
____ This is an address change.
____ This is a party change.
Assigned ID
Last Name
First Name
Middle Name
Mr.
Jr.
Sr.
1
Mrs.
Miss
II. III. IV.
Ms.
Address Where You Live (See Section “C” Below)
Apt. or Lot#
City/Town
County
State
ZIP Code
2
(Rural addresses must draw map.)
Address Where You Receive Mail If Different From Above
Apt. or Lot#
City/Town
County
State
ZIP Code
3
Party Affiliation (Optional)
Home & Work Phone Numbers (Optional)
4
5
6
Date of Birth _________/_________/_________
(H)
(W)
Month
Day
Year
8
E-mail Address (Optional)
Have you ever voted in a federal election in this State?
Yes
No
c
c
7
Signature of elector - Please sign full name or put mark.
ID Number - Check the applicable box and provide the appropriate number.
c Arkansas Driver’s license number _ ___________________________________
9
c If you do not have a driver’s license provide the last 4 digits of social
security number __________________________________________
c I have neither a driver’s license nor social security number.
The information I have provided is true to the best of my knowledge. I do not claim the right
(A) Are you a citizen of the United States of America and an Arkansas resident?
to vote in another county or state. If I have provided false information, I may be subject to
Yes
No
c
c
a fine of up to $10,000 and/or imprisonment of up to 10 years under state and federal laws.
(B) Will you be eighteen (18) years of age or older on or before election day?
Yes
No
c
c
Date:
_____________/_____________/_____________
(C) Are you presently adjudged mentally incompetent by a court of competent jurisdiction?
Month
Day
Year
10
Yes
No
c
c
If applicant is unable to sign his/her name, provide name, address and phone
11
(D) Have you ever been convicted of a felony without your sentence having been
number of the person providing assistance:
discharged or pardoned?
Yes
No
c
c
Name __________________________ Address: ________________________
If you checked No in response to either questions A or B, do not complete this form.
City:_____________________ State:_____ Phone#:_____________________
If you checked Yes in response to either questions C or D, do not complete this form.
Please complete the sections below if:
MAIL REGISTRANTS: PLEASE SEE SECTION D.
• You were previously registered in another county or state, or
Agency Code (For Official Use Only)
• You wish to change the name or address on your current registration.
Date of Birth
_________/_________/_________
Month
Day
Year
Mr.
Previous Last Name
First Name
Middle Name
Jr.
Sr.
A
Mrs.
Miss
II. III. IV.
Ms.
Previous House Number and Street Name
Apt. or Lot#
State
City/Town
County
ZIP Code
B
If you live in a rural area but do not have a house or street number, or if you have
no address, please show on the map where you live.
IDENTIFIcATIoN REQUIREmENTS
• Write in the names of the crossroads (or streets) nearest where you live.
• Draw an “X” to show where you live.
c
ImPoRTANT:
If your voter registration application
• Use a dot to show any schools, churches, stores or other landmarks near
where you live and write the name of the landmark.
form is submitted by mail and you are registering
for the first time, and you do not have a valid
Example
Arkansas driver’s license number or social security
NoRTH
D
number, in order to avoid the additional identification
•
Grocery
Store
requirements upon voting for the first time you
must submit with the mailed registration form: (a) a
Woodchuck Road
current and valid photo identification; or (b) a copy
•
Public School
of a current utility bill, bank statement, government
check, paycheck, or other government document
X
that shows your name and address.
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