Form C03 - State Of Alaska Voter Registration Application
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2STATE OF ALASKA VOTER REGISTRATION APPLICATION
Refer to instructions on the reverse side for specific information and identification requirements.
Please print clearly in blue or black ink.
You MUST complete this section for registration:
1.
I am a citizen of the United States.
Yes
No
I am at least 18 years old or will be within 90 days of completing this application.
Yes
No
If you checked NO to either question, do not complete this form as you are not eligible to register to
vote.
2.
Last Name
First Name
Middle Initial
Suffix
3.
Former Name:
(If your name has changed)
4.
You MUST provide the Alaska residence address where you claim residency. Do not use PO, PSC, HC or RR.
Alaska
House No.
Street Name
Apt No.
City
State
.
* Keep my residence address confidential
(Your mailing address in section 5 must be DIFFERENT from your
residence address in section 4 to remain confidential.)
5.
Mailing Address:
I am a voter with a disability and would like
(Address where you receive your
7.
mail if different from above)
information on alternative voting methods.
I am interested in serving as an election official.
8.
(Provide your phone number and/or email address in section 9.)
9.
Daytime Phone No.:
Evening Phone No.:
6.
*AK Voter Number:
Email Address:
(If known)
10.
Identifiers – You MUST provide at least one:
*Alaska Driver’s License
*SSN or Last 4 of SSN:
or State ID Number
I have not been issued a Social Security Number, Alaska Driver’s License or State ID number.
11.
You MUST provide:
12.
Gender
Male
Female
*Date of Birth
Month
Day
Year
13.
Political Affiliation For political affiliation choices in Alaska, see instruction number 5 on the reverse side.
Write political affiliation:
14
I am registered to vote in another state, cancel my registration in:
City:
State:
County:
Zip:
Voter Certificate. Read and Sign: I certify, under penalty of perjury, that the above information I provided on
this document is true and correct. I am not registered to vote in another state, or I have provided information to
cancel that registration. I further certify that I am a resident of Alaska and I have not been convicted of a felony, or
having been so convicted, have been unconditionally discharged from incarceration, probation and/or parole.
WARNING: If you provide false information on this application you can be convicted of a misdemeanor AS 15.56.050.
*SIGNATURE:
DATE:
Your signature must be a handwritten signature. A typed or digital signature is not valid.
Registrar/Agency/Official – Check ID and complete this section
OR
Registrar Name
Voter No or SSN
Agency Name
*Items are kept confidential by the Division of Elections and are not available for public inspection except that confidential addresses may
be released to government agencies or during election processes as set out in state law.
C03 (Rev. 09/19/2017)
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