Form Njdoe-Lv - Voter Registration Application

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Please fill out and print the completed form. YOU MUST SIGN YOUR NAME and then mail to the appropriate county in order to be registered.
New Jersey
76
Voter Registration Application
Please print clearly in ink. All information is required unless marked optional.
FOR OFFICIAL
Check boxes
New Registration
Address Change
Political Party Affiliation
1
USE ONLY
that apply:
Name Change
Signature Update
or Non-affiliation Change
Clerk
2
Are you a U.S. Citizen?
Will you be 18 years of age by the next election?
Yes
No
Yes
No
(If No, DO NOT complete this form)
(If No, DO NOT complete this form)
Registration #
3
Last Name
First Name
Middle Name or Initial
Suffix
(ex. Jr., Sr., III)
Office Time Stamp
4
Date of Birth
(MM/DD/YY)
5
NJ Driver’s License Number or MVC Non-driver ID Number
If you DO NOT have a NJ Driver’s License or MVC Non-Driver
ID, provide the last 4 digits of your Social Security Number.
“I swear or affirm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”
6
Home Address
Apt.
Municipality
State
County
Zip Code
(DO NOT use PO Box)
7
Mailing Address if different from above
Apt.
Municipality
County
State
Zip Code
8
Last Address Registered to Vote
Apt.
Municipality
County
State
Zip Code
(DO NOT use PO Box)
by mail
in person
Former Name if Making Name Change
Day Phone Number
9
(Optional)
Do you wish to declare a political party affiliation?
Yes, the party name is
(Optional)
10
No, I do not wish to be affiliated with any political party.
11
Gender
Declaration - I swear or affirm that:
I will have resided in the State and county
I understand that any false or
I am a U.S. Citizen
at least 30 days before the next election
fraudulent registration may subject
Female
I live at the above address
I am not on parole, probation or serving a
me to a fine of up to $15,000,
sentence due to a conviction for an indictable
Male
I will be at least 18 years old
imprisonment up to 5 years,
offense under any federal or state laws
on or before the next election
or both pursuant to R.S. 19:34-1
If applicant is unable to complete this form, print the
Signature: Sign or mark and date on line below
name and address of individual who completed this form.
Name
Date
X
Address
Date
Important Instructions for sections 5, 6 and 10
5) Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not have any of the
information required by section 5, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and
valid photo id, or a document with your name and current address on it to avoid having to provide identification at the polling place.
Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers
illegally shall be subject to criminal penalties.
6) If you are homeless, you may complete section 6 by providing a contact point or the location where you spend most of your time.
10) You may declare a political affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. Completing
section 10 is Optional and will not affect the acceptance of your voter registration application.
Need More Information?
Check boxes below if you would like to receive more information about:
voting by mail
polling place accessibility
available election materials in this
alternative language:
becoming a poll worker
voting if you have a disability,
including visual impairment
For further information visit or call toll-free 1-877-NJVOTER (1-877-658-6837)
NJDOE-lv-8/3/09

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