Kansas Voter Registration Application Form - Secretary Of State

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Voter Registration Instructions
You can use this application to:
*
Identification number requirements
Enter your current Kansas driver's license number or the last four
register to vote in Kansas, change your name or your address
digits of your Social Security number. If you do not have either
on your registration, affiliate with a political party, or change
number, write "none" in the box. The number will be used for
your party affiliation.
administrative purposes only and will not be disclosed to the public
To register to vote you must:
(KSA 25-2309).
be a U. S. citizen and a resident of the State of Kansas.
Notice to first-time voters
have reached the age of 18 years before the next election.
have received final discharge from imprisonment, parole, or
If you will be voting for the first time in this county, and do not provide
conditional release if convicted of a felony.
an identification number as requested above, you must complete
have abandoned your former residence and/or name.
one of the following options.
a) Send a copy of a current, valid photo ID along with your
How to register to vote
application, or
Return your completed application to your county. Addresses
b) Send a copy of a current utility bill, bank statement, paycheck,
are on the back of this application. Your county election officer
government check, or other government document that shows
will mail you a notice when your application has been processed.
your name and address.
Postmark this application by the 15th day before an election
If these requirements are not met or, if the information you provide
in order to be eligible to vote in that election.
is not verified, you must provide identification the first time you vote
If you decline to register to vote, that fact will remain confiden-
in the county.
tial and will be used for voter registration purposes only. If you
do register to vote, the office where you apply will be kept
For further information contact the Office of the Secretary of State,
confidential and will be used for voter registration purposes only.
1-800-262-VOTE (8683) V/TTY. This form is available at
If this form is incomplete, it may be rejected.
Print in blue or black ink, fold on center line, seal and return.
Kansas Voter Registration Application
Print
Reset
Qualifications: If you mark "NO" in response to either of these questions, do not complete this form.
Are you a citizen of the United States of America?
YES
NO Will you be 18 years of age on or before Election Day?
YES
NO
Personal Information
Please print
First Name
Middle
Jr. Sr. II III IV
Last Name
Residence address (include apt. or space number)
City
County
Zip
Section/Township/Range
(if rural route)
Date Residence established
Mailing address (if different than residence address)
City
Zip
Male
Female
/
/
Month
Day
Year
Date of Birth
Naturalization number (if applicable)
Daytime phone number (if available)
Driver's license number or last four digits of
*
Social Security number
/
/
Month
Day
Year
Party Affiliation
Choose one of the following:
Democratic
Republican
Libertarian
Reform
Not affiliated with a party
Complete if previously registered
Please print
Previous name
Previous address
City
State
Zip
County
Signature
I swear or affirm that I am a citizen of the United States and a Kansas resident, that I will be 18 years old before the next election, that if convicted of a felony,
I have had my civil rights restored, that I have abandoned my former residence and/or other name, and that I have told the truth on this application.
Sign here
Date today
Warning: If you submit a false voter registration application, you may be convicted and sentenced to up to 17 months in prison.
Ward
Pct
School Dist
Member Dist
FOR OFFICE USE ONLY:
Sen
Rep
CoComm

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