Voter Registration Application Form

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76
New Jersey
Voter Registration Application
Please print clearly in ink. All information is required unless marked optional.
1
Check boxes
New Registration
Address Change
Political Party Affiliation
FOR OFFICIAL
o
o
o
USE ONLY
that apply:
Name Change
Signature Update
or Non-Affiliation Change
o
o
Are you a U.S. Citizen?
Yes
No
Are you at least 17 years of age?
Yes
No
Clerk
2
o
o
o
o
(If No, DO NOT complete this form)
(If No, DO NOT complete this form)
Registration #
3
First Name
Middle Name or Initial Suffix
Last Name
(Jr., Sr., III)
Office Time Stamp
4
Date of Birth
NJ Driver’s License Number or MVC Non-driver ID Number
5
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.
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __
o
“I swear or affirm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”
Home Address
Apt.
Municipality
County
State
Zip Code
6
(DO NOT use PO Box)
Mailing Address if different from above
Apt.
Municipality
County
State
Zip Code
7
Last Address Registered to Vote
Apt.
Municipality
County
State
Zip Code
by mail
8
o
(DO NOT use PO Box)
in person
o
Former Name if Making Name Change
9
a. Day Phone Number
(Optional)
b. E-Mail Address
(Optional)
10
Do you wish to declare a political party affiliation?
Yes, the party name is
.
o
(Optional)
No, I do not wish to be affiliated with any political party.
o
Declaration - I swear or affirm that:
l I will have resided in the State and county
11
l I understand that any false or
Gender
l I am a U.S. Citizen
at least 30 days before the next election
fraudulent registration may subject
Female
o
l I live at the above address
l I am not on parole, probation or serving a
me to a fine of up to $15,000,
Male
l I am at least 17 years old, and under-
sentence due to a conviction for an indictable
imprisonment up to 5 years, or
o
stand that I may not vote until reaching
offense under any federal or state laws
both pursuant to R.S. 19:34-1
the age of 18.
If applicant is unable to complete this form, print the
Signature: Sign or mark and date on lines below
name and address of individual who completed this form.
Name
Date
Address
X
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 party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a
previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than
55 days before the primary election in order to vote in the primary election. 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:
o voting by mail
o polling place accessibility
o available election materials in
o becoming a poll worker
o voting if you have a disability,
this alternative language:
including visual impairment
For further information visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837)
NJ Division of Elections - 03/16/16

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