Commonwealth Of Pennsylvania Voter Registration Mail Application
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1
2Commonwealth of Pennsylvania
REGISTER
Voter Registration Mail Application
AND
VOTE
To Register You Must:
• Be a citizen of the United States for at least one month before the next election;
• Be a resident of Pennsylvania and your election district for at least 30 days before the
next election; and
• Be at least 18 years of age on the day of the next election.
GENERAL INSTRUCTIONS
ADDITIONAL INSTRUCTIONS
1. If you are currently registered, you do not need to re-register unless you have moved or changed
Box 5 You must supply a PA Driver’s License # or PennDOT ID #, if you
your name since you last registered.
have one. If you do not have either, you must supply the last four digits of
your Social Security Number. If you do not have a Social Security Number,
2. In order to vote at the next election, this application must be received by your county voter
please check the box at the far right.
registration office no later than 30 days before the election, or postmarked no later than the thirtieth day
before the election. Military electors may apply at any time. For more information on military and overseas
Box 6 P.O. boxes may not be used unless there is no physical address. If
electors, see
your address of residence listed has no street number or street name, use
the box below to draw a map of where you live. Include landmarks and
3. Write the mailing address for your county voter registration office on the reverse side of this application and
roads.
place the proper postage in the designated area. Addresses for all Pennsylvania counties are listed on the back
Box 9 If you were registered before, fill in the name, address, county and
of this form.
year of used on your previous registration.
4. You are not registered to vote until your application has been processed and accepted by the county voter
registration office. If accepted, the county voter registration office will send you, via nonforwardable mail,
Box 11 If you are unable to complete or sign the
a Voter ID Card. If you do not receive a Voter ID Card within 14 days of the date you submit this application,
application, the person who assisted you must provide his/her name,
contact your county voter registration office.
address, and signature.
5. If you decline to register to vote, your decision will remain confidential. If you register to vote, the office at
Box 12 Please read the registration declaration carefully. You must sign
which you register will remain confidential and be used for voter registration purposes only.
and print your name and date the application.
6. Do not use staples or duct tape.
Box 13 If you were assigned a Voter ID number, which appears on your
Voter ID Card, place that number, if available, here. If you are applying to
7. Print and sign clearly in blue or black pen.
register to vote for the first time, leave this box blank.
PENALTY FOR FALSIFYING REGISTRATION DECLARATION:
If a person signs an official resignation application knowing a statement declared in
the application to be false, makes a false registration, or furnishes false information,
the person commits perjury. Perjury is punishable, upon conviction, by a term of
imprisonment not exceeding seven years, or a fine not exceeding $15,000, or both, at
the discretion of the court. Submitting an application containing false information may
also subject a person to other penalties, including loss of the right of suffrage, under
state or federal law.
PENNSYLVANIA VOTER REGISTRATION APPLICATION
1
Yes
No
Are you a citizen of the United States of America?
“
”
if you checked
no
in response to either of
,
.
Will you 18 years of age on or before election day?
Yes
No
these questions
do not complete this form
2
Federal or State employees
Change of Address
Change of Party
New Registration
Change of Name
check here
/
Jr. Sr.
II III IV
last name
first name
middle name
initial
3
M
F
(
)
circle if applicable
’
#:
# (
4
):
I DO NOT have a PA Driver’s License or
pa driver
s license
ss
last
digits
4
or
or
(
)
(
#)
Social Security Number.
if you have one
if no pa dl
,
(
#
)
.
.
,
)
#
5
address of residence
include street and city
use map above if no street
or name
if only p
o
box
see above
apt
state
zip code
PA
# (
)
(
)
6
mailing address
if different from address of residence
city
state
zip code
telephone
optional
7
date of birth
/
/
(
)
8
race
optional
(
)
9
name on previous registration
address of previous registration
include street and city
county of previous registration
year of previous registration
(
’
)
10
party in which you wish to register
you must register with a party if you want to take part in that party
s primary
Democratic
Republican
No Affiliation
Other __________
Place signature with
full name (or mark) below.
11
name and signature of person who assisted in the completion of this application
complete address of person who assisted in the completion of this application
(
.)
please see penalty for falsifying declaration
12
I HEREBY DECLARE THAT:
AND I HEREBY AFFIRM THAT the information I have provided in this
On the day of the next election I will have been a united states citizen
registration declaration is true. I understand that this registration
for at least one month. I will be at least 18 years of age, will have
declaration will be accepted for all purposes as the equivalent of an
resided in pennsylvania and in my election district for at least 30 days
affidavit; and if the registration contains a materially false state-
and am legally qualified to vote.
ment, I will be subject to penalties for perjury.
13
# (
,
)
voter identification
if available
but not necessary
print name
14
reason for assistance
Do you require assistance when voting?
Yes
No
date
/
/
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