Pennsylvania Voter Registration Application (Page 2 of 3) in pdf

PENNSYLVANIA VOTER REGISTRATION APPLICATION

Are you a citizen of the United States of America?

Yes

If you checked “No” in response to either of

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Will you be 18 years of age on or before election day?

Yes

these questions, do not complete this form.

I am a Federal or State employee and wish to retain my voting

New Registration

Change of Name

Change of Address

Change of Party

residence in the county where I last resided.

Last Name

First Name

Middle Name/Initial

Jr Sr II III IV

(circle if applicable)

Place PA Driver’s

If no PA DL #, Place

I DO NOT have a PA Driver’s License

License (DL) # here

SS# (last 4 digits) here:

or Social Security Number.

if you have one:

Address of residence, include street and city (Use map above if no street number or name) (If only P.O. box, see above)

Apt #

State Zip Code

Telephone Number (Optional)

(

)

Municipality where you live

County where you live

Mailing Address (if different than address of residence)

City

State Zip Code

Date of Birth

Race (Optional)

Name on previous registration

Address of previous registration (include street and city)

County of previous registration Year of previous registration

In which party do you wish to register?

You must register with a party if you want to take part in that party’s primary.

Democratic

Republican

Libertarian

No affiliation

Other

Name and signature of person who assisted in the completion of this application

Place signatue with full name (or mark) below

(Please see Penalty for Falsifying Declaration.)

Address

I HEREBY DECLARE THAT:

(1) On the day of the next election I will have been a United States citizen

for at least one month. I will be at least 18 years of age, and I will have

resided in Pennsylvania and in my election district for at least 30 days;

(2) I am legally qualified to vote.

AND I HEREBY AFFIRM THAT the information I have provided in this

Print Your Name Below

Date:

registration declaration is true. I understand that this registration declaration will

be accepted for all purposes as the equivalent of an affidavit; and if the registration

contains a materially false statement, I will be subject to penalties for perjury.

Voter Identification Number

(If available - not necessary if you are registering to vote for the first time

or if you do not know your number.)

Do you require assistance

Reason for assistance:

when voting?

Yes

For more information on voting, please visit our educational web site:

If you do not receive your voter ID card in the mail within two weeks, call your county voter registration

or our toll-free

hotline 1-800-552-VOTE.

If you are interested in becoming a poll worker or a bilingual interpreter on Election Day, please check the boxes. Your county

voter registration

will contact you.

I would like to be a poll worker on Election Day

I would like to be a bilingual interpreter on Election Day

Specify Language:

Although providing your e-mail address is optional, it is a quick and easy way for your county voter registration

to contact

you in case there is missing information on your registration form:

IDENTIFICATION WHEN YOU VOTE

residence.)

DSBE-600 2/09

Pennsylvania Voter Registration Application Page 2

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