Form C03 - State Of Alaska Voter Registration Application printable pdf download

State of Alaska Voter Registration Application

You may use this form to register to vote or change your address, name or party affiliation

Print clearly. Use blue or black ink. Use all capital letters.

For Office Use Only

1. Last Name

First Name

M.I.

Suffix (Sr., Jr., III)

VN_______________

2. Name Previously Registered:

3. ALASKA Residence Address – You MUST Provide –

(Do not use PO, PSC, HC or RR)

D/P______________

House Number

Street Name

Apt. #

City

State

ALASKA

Codes/Comments/Initials

4. Mailing Address:

City

State

Zip Code

Date Received

11. Party Affiliation

*5. Alaska Voter No.:

(Select only ONE party choice)

*6. Social Security No.: ______-_____-_____

[ ] Alaskan Independence Party

[ ] Democrat Party

*7. Place of Birth:

[ ] Green Party

[ ] Libertarian Party

*8. Date of Birth: ______-______-______

[ ] Republican Party

[ ] Republican Moderate Party

*9. Daytime Phone No.:

[ ] Other:_______________________

Evening Phone No.:

[ ] Non-Partisan

[ ] Undeclared

10. Gender: [ ] Male

[ ] Female

12. I am currently registered to vote in another state. Please cancel that registration:

City:

State:

County:

Zip Code:

13. If you need special assistance to vote, indicate

14. If you would like to work at a polling place on election

the type of assistance needed below:

day, please provide your telephone number below:

I certify under penalty of perjury, that

15.

(Read the following statements and sign below):

♦

I am a United States citizen

♦

I will be at least 18 years old within 90 days of this registration

♦

I am a resident of Alaska

♦

I am not a convicted felon (unless unconditionally discharged)

♦

I am not registered to vote in another state, or I have included the necessary information to

cancel that registration

WARNING: If you provide false information on this application you can be convicted of a misdemeanor.

SIGNATURE:______________________ DATE:_______________

REGISTRAR OR AGENCY PLEASE COMPLETE THIS SECTION

_______________________________

__________________________________

____________________

Registrar or Agency Official Name

Title or Name of Agency

Voter # or SSN

FOR OFFICE USE ONLY

_____________________________

____________________________

Batch Number

No. of Applications Received

*Optional – Voter number, SSN, place of birth, date of birth, and telephone number are kept confidential and used for

identification only

C03 (REV 4/2001)

Form C03 - State Of Alaska Voter Registration Application

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