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Massachusetts Official

William Francis Galvin

Mail-In Agency Voter Registration Form

Secretary of the Commonwealth

How to use this form

You can use this form to:

1. Confirm your citizenship.

2. Print your name: last name, first name, middle name or initial.

• register or pre-register to vote in Massachusetts; and/or

3. Print your former name, if applicable.

• update your name, address, and political party.

4. Print the address where you live now: number and street name or rural

To register or pre-register to vote in Massachusetts you must:

route number and box number (do not provide a post office box number),

BE A U.S. CITIZEN;

apartment number, city or town and full zip code. Use the map

†

at right if

•

and

you cannot otherwise identify your address.

• be a Massachusetts resident; and

5. Print the address where you receive all your mail, if it is different from the

• be at least 16 years old.

address entered on #4.

Penalty for Illegal Registration: Fine of not more than

6. Print your date of birth: month, day and year. If you are 16 or 17 years old,

$10,000 or imprisonment for not more than five years or both.

you will be pre-registered until you are old enough to vote. You will be

-Massachusetts General Laws, chapter 56 section 8.

notified by mail when you become eligible to vote.

7. Federal law requires that you provide your driver’s license number to

Identification To Be Provided

license, you must provide the last four digits of your social security number.

Section 7 requires you to include your driver’s license number or the last 4

If you have neither, you must write “none” in the box.

digits of your social security number on this application. This information will

8. It is optional to provide your telephone number. If you include your

be verified through the Registry of Motor Vehicles and the Commissioner of

telephone number and do not check “unlisted” it will be a public record.

Social Security. If the information cannot be verified or you do not provide this

9. Check a party, ‘no party’ or print a political designation (not a party).

information, you must provide identification either with this application or at

10. Print the address where you were last registered to vote.

your polling location when you go to vote. Sufficient identification includes a copy

of a current and valid photo identification, current utility bill, bank statement,

11. If a person is helping you because you are physically unable to sign this

government check, paycheck or other government document showing your name

form, that assisting person must print his or her name and address and has

and address.

the option to print his or her telephone number.

12. Read the oath.

Using landmarks, draw the

†

north

13. Print today’s date.

location of the place where you

14. Sign your name.

live if you cannot describe that

east

west

This form may be mailed or hand-delivered to your city or town hall. If mailed,

location as a number and street or

fold the form, tape it closed, place a first class stamp on it, print your city or

as a rural route and box number.

south

town name and zip code for that city or town hall and drop into any mailbox.

Print all information in black ink. Follow above instructions for proper delivery.

Check one: Are you a Citizen of the United States of America?

Yes

No NOTE: If you checked “no,” do not complete this form.

■

Full name:

last name

first name

middle name or initial

Jr. Sr. II III IV

Miss Ms. Mrs. Mr.

(circle one if appropriate)

Former name:

last name

first name

middle name or initial

Jr. Sr. II III IV

Miss Ms. Mrs. Mr.

(circle one if appropriate)

Address where you live now (

street number / street name / rural route number & box number / apartment number / city or town / zip code

Address where you receive all your mail (if different from #4):

Date of birth:

Identification #:

Telephone (optional):

Check if unlisted

■

month day year

license # or last 4 digits of SSN

Party enrollment or designation (check one):

Democratic

Republican

Green-Rainbow

■

United Independent Party

No Party (unenrolled)

Political Designation (not a political party):

■

Address at which you were last registered to vote(

street number / street name / rural route number & box number / apartment number / city or town / zip code

If the applicant is unable to sign this form, give the name, address and telephone number (optional) of the person helping the applicant:

name

address

telephone number (optional)

I AM A CITIZEN OF THE UNITED STATES,

I hereby swear (affirm) that I am the person named above, that the above information is true, that

that I am at least 16 years

old and I understand that I must be 18 years old to be eligible to vote, that I am not a person under a guardianship which prohibits my registering to vote, that I am not temporarily or

permanently disqualified by law from voting because of corrupt practices in respect to elections, that I am not currently incarcerated for a felony conviction, and that I consider this

residence to be my home. Signed under the penalty of perjury.

Today’s date:

Signed:

month day year

Sign your name here.

BBA

Agency

Designation: