Virginia Voter Registration Application Form
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4VIRGINIA VOTER REGISTRATION APPLICATION FORM
Use this form to register to vote in Virginia or report a change in name or address.
To register to vote in Virginia, you must:
!
IMPORTANT
Be a United States citizen
: 29
DEADLINE
DAYS BEFORE THE ELECTION
Be a resident of Virginia
This form must be postmarked (or delivered to the county or city voter registration
Be 18 years old by the next general election
office or DMV) no later than 29 days before the election in which you plan to vote.
However, if you are already registered to vote at your current address, you do not
Have had your voting rights restored if you have ever been
need to re-register. Photocopies of this application are accepted with an original
convicted of a felony
signature. The only time faxes are accepted is for an address change.
Have had your capacity restored if you have ever been
declared mentally incapacitated in a Circuit Court.
PRIVACY ACT NOTICE: Article II, Section 2 of the Constitution of Virginia (1971) requires that a person registering to vote provide his or her social security number, if any. Therefore, if you do not provide
your social security number, your application for voter registration will be denied. Section 7 of the Federal Privacy Act (Public Law Number 93-579) allows the Commonwealth to enforce this requirement,
but also requires that you be advised that state and local voting officials will use the social security number as a unique identifier to ensure that no person is registered in more than one place. This
registration card will not be open to inspection by the public. Your social security number will appear on reports produced only for official use by voter registration and election officials, and for jury selection
purposes by courts.
WARNING: INTENTIONALLY MAKING A FALSE STATEMENT ON THE VOTER REGISTRATION APPLICATION CONSTITUTES THE CRIME OF ELECTION FRAUD,
WHICH IS PUNISHABLE UNDER VIRGINIA LAW AS A FELONY. VIOLATORS MAY BE SENTENCED TO UP TO 10 YEARS IMPRISONMENT, OR UP TO 12 MONTHS IN
JAIL, AND FINED UP TO $2,500.
: You must answer the boxes 1 – 11. If you do not complete all of the specified boxes your application will
ATTENTION
be denied. Once your local registrar approves your application, you should receive a voter card.
Commonwealth of Virginia
1
PREVIOUS VOTER REGISTRATION INFORMATION (REQUIRED)
I have never registered to vote in the past.
► If NO, skip to Box 2.
NO
YES I am registered to vote at another address in Virginia or in another state.
► If YES, the information below must be completed.
FULL LEGAL NAME ______________________________________________________________________________________
DATE OF BIRTH
ADDRESS AT WHICH YOU WERE
PREVIOUSLY REGISTERED TO VOTE
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER________
CITY/TOWN
STATE
ZIP CODE
CITY/COUNTY/TOWN OF RESIDENCE (IF APPLICABLE) ____________________________
This cancellation information will be sent to the county or city and state you entered above.
V
- 1
IRGINIA
If you checked ‘no’ in response to
Are you a citizen of the United States of America?
Will you be 18 years of age on or before election day?
2
either of these questions, do not
YES
NO
YES
NO
complete this form.
SOCIAL SECURITY NUMBER
GENDER
DATE OF BIRTH
3
4
5
MALE
FEMALE
____ ____ / ____ ____ / ____ ____ ____ _____
M
M
D
D
Y
Y
Y
Y
LAST NAME [Print]
FIRST NAME
FULL MIDDLE OR MAIDEN NAME
DAYTIME TELEPHONE NUMBER
SUFFIX [JR., SR., III, ETC.]
6
RESIDENCE /HOME ADDRESS (
,
)
APT/UNIT/LOT/RM/SUITE
CITY OR TOWN
ZIP CODE
IF RURAL ADDRESS
DESCRIBE BELOW
7
RURAL ADDRESS,
IF
(
.
.,
?
–
,
,
.;
)
DESCRIBE WHERE YOUR HOUSE IS LOCATED
I
E
WHAT IS THE STATE ROAD NUMBER WHERE YOUR HOUSE IS LOCATED
WHICH SIDE OF THE ROAD
NORTH
EAST
ETC
NEAREST LANDMARK
MAILING ADDRESS (if different) V
P. O. BOX OR UNIFORMED SERVICE ADDRESS,
[
]
NAME OF CITY OR COUNTY OF RESIDENCE
IRGINIA
IF APPLICABLE
INCLUDE ZIP CODE
8
CITY
OR
COUNTY
OF
HAVE YOU EVER BEEN CONVICTED OF A FELONY?
YES
NO
HAVE YOU EVER BEEN JUDGED MENTALLY INCAPACITATED?
YES
NO
10
9
IF YES, HAVE YOUR VOTING RIGHTS BEEN RESTORED?
YES
NO
IF YES, HAS COURT RESTORED YOU TO CAPACITY?
YES
NO
IF YES, WHEN RESTORED? (R
)
______
______
______
IF YES, WHEN RESTORED? (R
)
______
______
______
EQUIRED
MO
DAY
YEAR
EQUIRED
MO
DAY
YEAR
REGISTRATION STATEMENT:
/
,
,
.
.
,
I SWEAR
AFFIRM
UNDER FELONY PENALTY FOR MAKING WILLFULLY FALSE MATERIAL STATEMENTS OR ENTRIES
THAT I AM A U
S
CITIZEN AND A RESIDENT OF VIRGINIA
THE
,
(
1
)
,
.
INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE
I AUTHORIZE THE CANCELLATION
ENTERED IN BOX
ABOVE
OF MY CURRENT REGISTRATION
AND I HAVE READ THE PRIVACY ACT NOTICE ABOVE
: SIGN HERE
(
).
11
REMINDER
FOR VOTER REGISTRATION
OR MARK IF UNABLE TO SIGN
►
S
IGN
H
ERE
DATE
If applicant is unable to sign, write below the name/address of person who assisted: (REQUIRED)
Yes, I am interested in
Check here if you have a
You may request that your home address not be released if you (a) are active or retired law enforcement, or (b) have
disability that requires
working as an Election
been granted a protective court order, or (c) are in fear of your personal safety from someone who has threatened or
accommodation in order to vote.
stalked you and have filed a complaint against that person with a magistrate or law enforcement (must attach copy of
Official on Election Day.
complaint). You must show a Virginia P.O. box under mailing address in Box 7 above.
Please send me information.
ACTIVE/RET LAW ENFORCEMENT
PROTECTIVE COURT ORDER
THREATENED/STALKED
COMMENTS
REGISTRATION DATE
PCT
TOWN CODE
DENIAL DATE & REASON
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