Voter Registration Application
Before completing this form, review the General, Application, and State specific instructions.
Yes
No
Are you a citizen of the United States of America?
This space for office use only.
Yes
No
Will you be 18 years old on or before election day?
If you checked "No" in response to either of these questions, do not complete form.
(Please see state-specific instructions for rules regarding eligibility to register prior to age 18.)
II
Last Name
First Name
Middle Name(s)
Mr.
Miss
Jr
1
III
Mrs.
Ms.
Sr
IV
Home Address
Apt. or Lot #
City/Town
State
Zip Code
2
Address Where You Get Your Mail If Different From Above
City/Town
State
Zip Code
3
Date of Birth
Telephone Number (optional)
ID Number -
(See item 6 in the instructions for your state)
4
5
Month
Day
Year
6
Choice of Party
Race or Ethnic Group
7
(see item 7 in the instructions for your State)
8
(see item 8 in the instructions for your State)
I have reviewed my state's instructions and I swear/affirm that:
I am a United States citizen
■
I meet the elig ibility requirements of my state and
■
subscribe to any oath required.
9
Please sign full name (or put mark)
The information I have provided is true to the best of my
■
knowledge under penalty of perjury. If I have provided false
Date:
information, I may be fined, imprisoned, or (if not a U.S.
citizen) deported from or refused entry to the United States.
Month
Day
Year
If you are registering to vote for the first time: please refer to the application instructions for information on submitting
copies of valid identification documents with this form.
Please fill out the sections below if they apply to you.
If this application is for a change of name, what was your name before you changed it?
II
Last Name
First Name
Middle Name(s)
Mr.
Miss
Jr
A
III
Mrs.
Ms.
Sr
IV
If you were registered before but this is the first time you are registering from the address in Box 2, what was your address where you were registered before?
Street (or route and box number)
Apt. or Lot #
City/Town/County
State
Zip Code
B
If you live in a rural area but do not have a street number, or if you have no address, please show on the map where you live.
NORTH
Write in the names of the crossroads (or streets) nearest to where you live.
■
Draw an X to show where you live.
■
Use a dot to show any schools, churches, stores, or other landmarks
■
near where you live, and write the name of the landmark.
Example
C
Grocery Store
●
Woodchuck Road
Public School
X
●
If the applicant is unable to sign, who helped the applicant fill out this application? Give name, address and phone number (phone number optional).
D
Mail this application to the address provided for your State.