Oklahoma Voter Registration Application Page 3
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3OKLAHOMA VOTER REGISTRATION APPLICATION
USE BLUE OR BLACK INK
*OK93140270W*
Fold the application and place it in an envelope.
270-W
OK93140-
Mail it to:
OKLAHOMA STATE ELECTION BOARD
P.O. BOX 528800
Oklahoma City, OK 73152-880
Precinct
Activation Date
CEB Use Only
Voter ID
Suffix (Print)
1. Last Name (Print)
First Name (Print)
Middle Name (Print)
.
Jr., Sr., II, etc
3. Identification Number (See Instructions.)
2. Birth Date
Month Day Year
a. Oklahoma Driver License Number b. Last Four Numbers of Social Security Number
c.
I do not have a driver license
(Required)
(Required if no driver license)
or a Social Security Number.
4. Political Party (See Instructions.)
Democratic Party
Republican Party
No Party
Other
City
State
ZIP code
5. Street or 911 Address or directions to your home
(Do not use a rural route or PO Box. See Instructions.)
City
State
ZIP code 7. County of Residence
6. Mailing Address
9. Oath (See Instructions.)
8. Have you been registered before? (See
Are you a citizen of the United States of America?
Instructions)
YES
NO
Will you be 18 years of age on or before election day?
YES
NO
Yes
No
If you marked YES above, please give the
If you check NO in response to either of these questions,
following information.
DO NOT sign or submit this form.
Former Name
Former Party
I swear or affirm that:
I am a citizen of the United States and I am a resident of the State of
Former Residence Address
Oklahoma.
I am 18 years old or older, or I will be 18 on or before the date of the
next election.
I have not been convicted of a felony, or if I have been convicted of a
City
County
State
felony, a period of time equal to the original sentence has expired, or I
have been pardoned.
I am not now under judgment as an incapacitated person. I am not
Voter ID Number
under judgment as a partially incapacitated person prohibited from
voting.
The information I have given is true. I reside at the address given. I
If someone helped you fill out this application, the
understand that submitting false information on this form is a felony
.
helper should write his/her name and address here
punishable by not more than 5 years in prison, by a fine of not more than
$50,000.00, or both.
X
Signature or Mark of Applicant
Date
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