Pennsylvania Voter Registration Application printable pdf download

PENNSYLVANIA VOTER REGISTRATION

MAIL APPLICATION

To Register You Must:

Be a citizen of the United States for at least one month before the next election;

AND

Be a resident of Pennsylvania and your election district for at least 30 days

VOTE

before the next election; and

Be at least 18 years of age on the day of the next election.

GENERAL INSTRUCTIONS

1. Please provide all information on the application as required. Read all instructions carefully before you

fill out the application.

2. If you are currently registered, you do not need to re-register unless you have moved or changed your

name since you last registered.

3. In order to vote in the next election, this application must be received by your county voter 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

electors, see

4. Write the mailing address for your county voter registration office on the reverse side of this

application and place the proper postage in the designated area. Addresses for all Pennsylvania

counties are listed on the back of this form.

5. 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, a Voter Identification Card. If you do not receive a Voter Identification Card

within 14 days of the date you submit this application, contact your county voter registration office.

6. If you decline to register to vote, your decision will remain confidential. If you register to vote, the

office at which you register will remain confidential and be used for voter registration purposes only.

7. Do not use staples or duct tape.

8. Print and sign clearly in blue or black pen.

3b Pennyslvania Driver’s License OR Social Security Number: You

Prior Registration: If you were registered before, fill in the name used

must supply a PA Driver’s License Number if you have one. If you do

on your previous registration in Box 8a and address, county and year of

not have a PA Driver’s License Number, you must supply the last four

previous registration in Box 8b.

digits of your Social Security Number. If you do not have a Social

Security Number, please check the box to the right of 3b.

Name of Assistant: If the applicant is unable to complete or sign the

application, the person who assisted the applicant must provide his or her

name, address and signature.

4a Address of Residence: Fill in your complete address of residence.

P.O. boxes may not be used here unless there is no physical address.

Print street address, city and zip code. (If the residence is only a portion

Registration Declaration: You must be a citizen of the United States to

of the house, include the location of the room, apartment or

floor which is occupied.)

4b Although providing your telephone

registration declaration carefully. You must sign and print your name and

number is optional, it is a quick and easy way for your county to

date the application.

contact you if there is missing information on your registration form.

If you were assigned a Voter Identification Number, which appears on

your Voter Identification Card, place that Identification Number, if

In Box 4c fill in the name of the municipality (city, borough or

available here. If you are applying to register to vote for the first time,

township) and county where you live. Use the map in the box below if

leave this box blank.

you cannot otherwise identify your address.

If you require assistance when voting, you must check the box and provide

the reason.

PENALTY FOR FALSIFYING REGISTRATION DECLARATION

WARNING: If a person signs an official registration 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

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