Form 06w - North Carolina Voter Registration Application - The State Board Of Elections And Ethics Enforcement

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06w

NORTH CAROLINA VOTER REGISTRATION APPLICATION

Please use black ink and print legibly.

Yes

Will you be at least 18 years of age on or before election day?

Are you a citizen of the United States of America?

Are you at least 16 years of age and understand that you must be 18 years

Yes

of age on or before election day to vote?

IF YOU CHECKED "NO" IN RESPONSE TO THIS QUESTION,

IF YOU CHECKED "NO" IN RESPONSE TO BOTH OF THESE QUESTIONS,

DO NOT SUBMIT THIS FORM.

Last Name

(Required)

Date of Birth MMDDYYYY

(Required)

State of Birth/Country of Birth

First Name

(Required)

If you know your NC Voter Registration Number, enter it below.

Middle Name

(Required)

If you have a NC drivers license or non-operators ID card, enter the number below.

Enter the last 4 digits of your SSN.

Check here if you do not have a NC

Jr.

Sr.

III

drivers license, ID card, or a SSN.

RESIDENTIAL ADDRESS INFORMATION - No P.O. Boxes or Rural Routes

Street Address where you live

(Required)

Apartment, Lot, or Unit Number

City

(Required)

State

Zip Code

N C

County

Phone (Optional)

If "No," date moved? MMDDYYYY

Have you lived here

Yes

for 30 days or more?

MAILING ADDRESS

MAP/DIAGRAM

Mailing Address (If you do not receive mail at your residential address)

If you do not have a street address, draw a map of where

you reside. Please include roads and landmarks.

Mailing Address Line 2

City

State

Zip Code

GENDER

RACE

ETHNICITY

POLITICAL PARTY AFFILIATION

African American/

American Indian/

Hispanic/Latino

Democrat

Republican

Libertarian

Female

Black

Alaska Native

Asian

Multiracial

Not Hispanic/ Latino

Unaffiliated

Other

Male

If you indicate a political party that is not currently qualified, or

White

Other

you do not indicate a choice, you will be listed as "Unaffiliated."

PREVIOUS VOTER REGISTRATION (This information will be used to cancel your previous voter registration in another county or state.)

Last Name used in Previous Registration

First Name used in Previous Registration

Previous Address

Previous County

Previous City

Previous State

Previous Zip Code

I attest, under penalty of perjury, that in addition to having read and understood the contents of this form, that:

· I am a United States citizen, as indicated above;

· I am at least 18 years of age, or will be by the date of the general election; or I am at least 16 years old and understand that I must be at least 18 years old on

election day of the general election to vote;

· I shall have been a resident of North Carolina, this county, and precinct for 30 days before the election in which I intend to vote;

· I will not vote in any other county or state after submission of this form and if I am registered elsewhere, I am canceling that registration at this time; and

· I have not been convicted of a felony, or if I have been convicted of a felony, I have completed my sentence, including any probation or parole.

(Citizenship and voting rights are automatically restored upon completion of the sentence. No special document is needed.)

Fraudulently or falsely completing this

form is a Class I Felony under Chapter

163 of the NC General Statutes.

Signature

(Required)

Date

version092016