Fillable Alaska Voter Registration Application printable pdf download

Use this form only to register to vote; change your address, name, or party affiliation.

When completed, fill out appropriate PFD applications, and submit.

You must fully complete a dividend application to be eligible for the dividend program.

Alaska Voter Registration Application

CAUTION: SSN is optional, but

M.I.

Suffix

2. Previous name

1. Last Name

First Name

if not provided, 31% of your

dividend will be withheld as

required by federal law.

3. Alaska Residence Address — Where You Live (DO NOT use PO, PSC or RR Box)

Residence Address

City

ALASKA

4. Mailing Address

City

State

Zip Code

5. Please cancel my registration in:

City:

County:

State:

Zip Code:

6. Social Security Number

7. Place of Birth

8. Date of Birth

9. Alaska Voter Number 10.Daytime Phone #:

Evening Phone #:

12. Party Affiliation (Please check one)

11. Sex

Democrat

Green

Alaskan Independence

Male

Republican

Other______________

Undeclared

Non-Partisan

Female

13. Voter Oath— Read and sign below. I certify under penalty of perjury, that:

I am a United States Citizen

I am not a convicted felon (unless unconditionally discharged)

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

I am a resident of Alaska

necessary information to have that registration cancelled.

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

Eligibility Verification by Two Adults Who Know You

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

Signature ________________________________________________________________ Date ___________________________________

For Office Use Only:

Codes/Comments/Initials:

VN _____________________

D/P ____________________

C-03PFD (REV 9/97)

Alaska Voter Registration Instructions

Item 1 - NAME. (MANDATORY) Print or type your full name:

Item 4 - MAILING ADDRESS. (MANDATORY)

ndicate your mail-

last, first, middle initial and suffix (i.e. Jr., Sr., III).

ing address. Provide a specific street address, postal box number,

along with city, state and zip code OR indicate “Same as Resi-

Item 2 - PREVIOUS NAME. (MANDATORY) If your name has

dence Address” if applicable.

changed, provide the name in which you were previously regis-

tered and sign your new name.

Item 5 - CANCEL REGISTRATION IN ANOTHER STATE. (MAN-

DATORY) This section only applies to you if you are registered to

Item 3 - ALASKA RESIDENCE ADDRESS. (MANDATORY) A

vote in another state. Complete this section with the city, county,

physical residence address enables you to be assigned to a pre-

state and zip code of the location of your prior registration.

cinct. You must print your ALASKA RESIDENCE ADDRESS -

WHERE YOU LIVE. Your application will not be accepted for

Items 6, 7, 8, 9, 10 - CONFIDENTIAL INFORMATION. This infor-

processing if you use a P.O. Box, HC No. and Box, PSC Box,

mation is optional, however, it assists in maintaining your voter

Rural Route No., Commercial Address or Mail Stop Address. If

record and verifying your identity.

your residence has been assigned a street number, provide that

number. If not, indicate exactly where you live (i.e., highway

Item 11 - SEX. (MANDATORY) Check the appropriate box.

name and milepost number, boat harbor, pier and slip number,

subdivision name with lot and block or trailer park name and

Item 12 - POLITICAL PARTY AFFILIATION. Check the box next

space number).

to the party of your choice OR check “Other” and write the name of

your party.

Alaska residents registering from out of state must provide

proof of Alaska residency, such as a copy of a current Alaska

Item 13 - VOTER OATH. Read the oath carefully before you

driver’s license, hunting or fishing license, student loan

sign the application. You are signing the oath under penalty of

documents or Military Leave and Earnings Statement.

perjury. Sign exactly as you printed your name on the form.

Alaska Voter Registration Application

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