Application To Purchase Or View Voter Registration Information

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Complete Application To Purchase Or View Voter Registration Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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KERN COUNTY ELECTIONS

Date Sent/Picked Up: _______________

APPLICATION TO PURCHASE OR VIEW VOTER REGISTRATION INFORMATION

Pursuant to Elections Code Sections 2188, voter registration information is available ONLY to persons or groups who meet specific conditions, including the completion of a

written application. All requests to view, purchase, or use voter registration information must be accompanied by this application. If you download this file as a pdf file,

you may either print it directly to your own printer, complete the application with a pen, sign the application and send a copy of your Driver’s License with this completed

application to the address shown below OR fill in all the blanks using your computer, print the completed application on your printer, sign it and send it along with a copy

of your Driver’s License to the address shown below.

Name

: __________________________________________________________________________________________________________

First

Middle Initial

Last

Office use only:

Driver’s License Number: _____ ______________________

Verified By: ___________________________

Paid? _____________

State and Number

Deputy Initials

P/U or Mail? _______

Residence Address

________________________________________________________________________________________________

Number and Street Name

________________________________________________________________ (_______)_______________________

City

State

Zip Code

Telephone Number

Business Address

________________________________________________________________________________________________

Number and Street Name

_________________________________________________________________(_______)______________________

City

State

Zip Code

Telephone Number

Shipping Address:

________________________________________________________________________________________________

Number and Street Name

__________________________________________________________________

City

State

Zip Code

If this application is on behalf of any person, group, or organization other than the applicant, this section must be completed.

Name

_________________________________________________________________________________________________

Person, group, or organization requesting / authorizing applicant to obtain voter information on their behalf

Address

_________________________________________________________________________________________________

Number and Street Name

_________________________________________________________________ (_______)_______________________

City

State

Zip Code

Telephone Number

THIS SECTION MUST BE COMPLETED

What type(s) of business, organization, or committee do you represent?

Political

Investigation

Private Vendor

Media

Educational

Legal

Governmental

Other:______________________________________

Candidate (Name&Office) _________________________________________________________________

Proposed ballot measure (Title/Number/Letter) _________________________________________________

Intended use of Voter Registration information:

Political Research

Initiative/Referendum

Governmental

Recall

Scholarly Research

Other: ________________________________

Explain in detail your intended use of this information. If more space is needed, attach explanation. (NOTE: use of voter registration files is limited.)