Form Eb-131 - Wi Voter Registration Application

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Submitted by Mail
Voter Registration Application
(Office Use Only)
SVRS ID #
Confidential Elector ID#
(HINDI - sequential #) (Office Use Only)
(Office Use Only)
General Instructions:
Please use uppercase (CAPITAL) letters only. Fill in circles as appropriate. Return completed form to municipal clerk.
Please Review Fully
This document can be made available in accessible formats to persons with disabilities, upon request.
NOTE: If this is a change of address, then upon completion of this application, your voting rights will be canceled at your
previous residence.
If you are registering to vote in Wisconsin for the first time and submitting this application by mail, you must provide
identification with this application. If you do not provide identification with this application, you will be asked for identification
the first time that you vote. Please see reverse side for a list of acceptable forms of identification.
Town
Municipality
Village
New WI Voter
City
1
Name Change
WI Address Change
County
I have neither a WI
-
-
-
Wisconsin Driver License/ID Number
Driver License/ ID
-
2
nor a Social
X
-
-
Social Security Number - Last Four Digits (if no license/ID number)
X X
X X
Security Number.
Last Name
Suffix
(e.g. Jr, II, etc.)
First Name
Middle Name
3
/
/
Date of Birth
(MM/DD/YYYY)
Residence Address: Street Number & Name
Apt. Number
City
4
-
State
ZIP + 4
Mailing Address: Street Number & Name
5
Apt. Number
City
State & ZIP + 4
Last Name
Suffix
(e.g. Jr, II, etc.)
6
First Name
Middle Name
Address: Street Number & Name
7
Apt. Number
City
State & ZIP + 4
Please answer the following questions by filling in “Yes” or “No”:
If you filled in ‘No” in response to EITHER of these
Yes
No
8
1. Are you a citizen of the United States of America?
questions, do not complete this form.
Yes
No
2. Will you be 18 years of age on or before election?
I certify that I am a qualified elector, a U.S. citizen, at least 18 years old, having resided at the above residential address for at least 10 days
immediately preceding this election, not currently serving a sentence including probation or parole for a felony conviction, and not otherwise
9
disqualified from voting. I certify that all statements on this form are true and correct. If I have provided false information I may be subject to
fine or imprisonment under State and Federal laws. If completed on election day: I further certify that I have not voted at this election.
(Please fill in circle)
Corroborating Witness/
Corroborating Witness/
X
10
Assistant Signature
Assistant Address
Elector Telephone Number
I am interested in being a poll worker.
11
Accommodation needed at poll location (e.g. wheelchair access):
If you do not have a street number or if you have no address, please use the map to show where you live:
> Write the names of the crossroads (or streets) nearest to where you live.
N
Example
Library
12
> Draw an ‘X’ to show where you live.
Woodchuck Road
> Use a dot to show any schools, churches, stores or other landmarks where
you live and write the name of the landmark.
X
High School
Date
/
/
(MM/DD/YYYY)
Signature of Elector
X
Official Use Only: Election Day Voter #
Official Use Only: Proof of Residence/ID:
Official Use Only: Proof #:
Official
Ward
Sch. Dist.
Alder.
Cty. Supr.
Ct. of App.
Assembly
St. Senate
Congress
Other
Official’s Signature (election official, or special registration deputy (with
Use
ID number))
Only:
EB-131 (REV 1/2006)

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