Voter Registration Application Form - New Jersey
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1
233
New Jersey
Voter Registration Application
Please print clearly in ink. All information is required unless marked optional.
1
Check boxes
New Registration
Address Change
Political Party Affiliation
FOR OFFICIAL
o
o
o
USE ONLY
that apply:
Name Change
Signature Update
or Non-affiliation Change
o
o
2
Will you be 18 years of age by the next election?
Yes
No
Are you a U.S. Citizen?
Yes
No
Clerk
o
o
o
o
(If No, DO NOT complete this form)
(If No, DO NOT complete this form)
3
Registration #
First Name
Middle Name or Initial Suffix
Last Name
(Jr., Sr., III)
4
Office Time Stamp
Date of Birth
5
NJ Driver’s License Number or MVC Non-driver ID Number
If you DO NOT have a NJ Driver’s License or MVC Non-Driver
__ __ __ __
ID, provide the last 4 digits of your Social Security Number.
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __
o
“I swear or affirm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”
County
State
Zip Code
6
Home Address
Apt.
Municipality
(DO NOT use PO Box)
7
Mailing Address if different from above
County
State
Zip Code
Apt.
Municipality
Last Address Registered to Vote
County
State
Zip Code
8
Apt.
Municipality
by mail
o
(DO NOT use PO Box)
in person
o
9
Former Name if Making Name Change
a. Day Phone Number
(Optional)
b. E-Mail Address
(Optional)
10
Do you wish to declare a political party affiliation?
Yes, the party name is
.
o
(Optional)
No, I do not wish to be affiliated with any political party.
o
Declaration - I swear or affirm that:
l I will have resided in the State and county
l I understand that any false or
11
Gender
l I am a U.S. Citizen
at least 30 days before the next election
fraudulent registration may subject
Female
l I live at the above address
l I am not on parole, probation or serving a
o
me to a fine of up to $15,000,
l I will be at least 18 years old
sentence due to a conviction for an indictable
imprisonment up to 5 years,
Male
o
on or before the next election
offense under any federal or state laws
or both pursuant to R.S. 19:34-1
If applicant is unable to complete this form, print the
Signature: Sign or mark and date on lines below
name and address of individual who completed this form.
Name
Date
X
Date
Address
Important Instructions for sections 5, 6 and 10
5) Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not have any of the
information required by section 5, or the information you provide cannot be verified, you will be asked to provide a COPY of a
current and valid photo ID, or a document with your name and current address on it to avoid having to provide
identification at the polling place.
Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such
numbers illegally shall be subject to criminal penalties.
6) If you are homeless, you may complete section 6 by providing a contact point or the location where you spend most of
your time.
10) You may declare a political affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation.
Completing section 10 is OPTIONAL and will not affect the acceptance of your voter registration application.
Need More Information?
Check boxes below if you would like to receive more information about:
o voting by mail
o polling place accessibility
o available election materials in
o becoming a poll worker
o voting if you have a disability,
this alternative language:
including visual impairment
For further information visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837)
NJ Division of Elections - 7/2014
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