National Voter Registration Application Form For U.s. Citizens Page 4

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Voter Registration Application

Before completing this form, review the General, Application, and State specific instructions.

Yes

Are you a citizen of the United States of America?

This space for office use only.

Yes

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.)

Last Name

First Name

Middle Name(s)

Mr.

Miss

III

Mrs.

Ms.

Home Address

Apt. or Lot #

City/Town

State

Zip Code

Address Where You Get Your Mail If Different From Above

City/Town

State

Zip Code

Date of Birth

Telephone Number (optional)

ID Number -

(See item 6 in the instructions for your state)

Month

Day

Year

Choice of Party

Race or Ethnic Group

(see item 7 in the instructions for your State)

(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.

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?

Last Name

First Name

Middle Name(s)

Mr.

Miss

III

Mrs.

Ms.

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

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.

■