North Carolina Voter Registration Application/update Form Page 2
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1
2North Carolina Voter Registration Application/Update Form
Print Information and Sign Below
06w
Print Form
I Attest, Under Penalty of Perjury, that: (Answer YES or NO to the following questions.)
YES
NO
I am a United States citizen.
I am 18 years old, or will be by general election day.
I have been a resident at this address for 30 days or more. If less than 30 days, I moved here on ____________(date).
I will not vote in any other county or state after submission of this form. If I am registered elsewhere, I am canceling that
registration at this time.
I have not been convicted of a felony; or if I have been convicted of a felony, my rights of citizenship have been restored.
If you checked "NO" in response to any of these questions, DO NOT COMPLETE THIS FORM
Section 1
Jr
II
IV
.
Full legal
Sr
III
Last Name
(Required)
First Name
(Required)
name and
birth date
Middle Name
(Required)
Place of Birth
Date of Birth - MM/DD/YYYY
(Required)
Do you have a NC driver's license or NC identification card
Section 2
Yes
No
issued by DMV? If yes, provide the number.
Personal
NC Driver License or Identification Number
If you do not have a DMV-issued card, do you have a U.S.-
Identification
X
X
X
X
X
Yes
No
issued Social Security Number? If yes, provide last 4 digits.
Number
Social Security Number (Last Four Digits)
Have you been assigned a NC State Voter Registration
(Required)
Yes
No
Number? If yes, provide unless you provided one of the
NC State Voter Registration Number
numbers above.
Section 3
Map/Diagram
Residence
If you do not have a street address, draw a map of where you
Street Address where you live - No P.O. Boxes or Rural Roads
Apt/Unit
Address
reside. Please include roads and landmarks.
(Required)
City
N C
County
State
ZIP Code
Have you lived here for 30 days or more?
Yes
If no, date moved __________________
No
Phone (Optional)
Section 4
Mailing
Address where you get your mail (If different from your residence address.)
Apt/Unit
Address
City
State
ZIP Code
Section 7
Section 6
Political Party Affiliation
Race/Ethnicity
Section 5
Female
Black/African
Gender
American Indian/
Asian
Other
Democratic
Republican
Unaffliated
American
Alaska Native
Male
Other
Hispanic/Latino
White
Two or More
Section 8
Name and
Last Name used in Previous Registration
First Name
address used
for your last
State
ZIP Code
voter
Previous Address
registration
if applicable
Previous City
Previous County
Signature
Date
I HAVE READ AND UNDERSTAND THE CONTENTS OF THIS FORM
WARNING: If you sign this card and know it to be false, you can be convicted of a Class I felony
To Mail - Place this completed and signed form in an envelope addressed to your local County Board of Elections office. Be
version112007-1web
sure to affix the proper USPS postage stamp.
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