Voter Registration Application Nevada Wic
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1
2SECRETARY OF STATE ROSS MILLER
Application No.
HA
STATE OF NEVADA
V O T E R R E G I S T R A T I O N A P P L I C A T I O N
BOX 3 - NAME Please write your name exactly as it appears on the
BOX 13 - ASSISTING IN THE COMPLETION OF THIS FORM If you are assisting
Nevada driver’s license, I.D. card, or Social Security card referenced in
a person to register to vote, you must complete Box 13. FAILURE TO DO SO IS A
Box 8. If you do not have any of these forms of identification, please see
FELONY.
the instructions for Box 8.
DEADLINES FOR SUBMITTING APPLICATION
By Mail—postmarked by Saturday, 31 days before an Election.
BOX 4 - HOME ADDRESS Your home address is the street address
In Person at DMV—by Saturday, 31 days before an Election.
assigned to the location at which you actually reside. If you reside at a
In Person At County Clerk’s or Registrar’s Office—by Tuesday, 21 days
location that has not been assigned a street address, a description of the
before an Election (for Municipal Elections, in person at City Clerk’s).
location at which you actually reside must be provided. A P.O. Box
For Special/Recall Elections—contact your County Clerk or Registrar.
cannot be listed as a home address.
BOX 8 - IDENTIFICATION REQUIREMENTS Federal and state law
NOTICE You are urged to return your application to register to vote to the
require you to provide your NV driver’s license or NV ID number. If you do
County Clerk/Registrar in person or by mail. If you choose to give your
not have either, you must provide the last 4 digits of your social security
completed application to another person to return to the County
number (SSN). If you do not have any of these three forms of
Clerk/Registrar on your behalf, and the person fails to deliver the
identification, please contact your County Clerk/Registrar after you have
application to the County Clerk/Registrar, you will not be registered to vote.
completed and returned this form.
Please retain the duplicate copy or receipt from your application to register
BOX 10 - PARTY REGISTRATION Mark your choice of a qualified party,
to vote.
“Nonpartisan” or “Other.” If you mark “Other,” you may print the name of
INTERESTED IN BEING A POLL WORKER? Please contact your local County
an unlisted political party. If you register with a minor political party or as
Clerk or Registrar’s Office. See Reverse.
a nonpartisan, you will receive a nonpartisan ballot for the Primary
Election.
CHECK THIS BOX TO RECEIVE A SAMPLE BALLOT IN LARGER TYPE
WARNING: GIVING FALSE INFORMATION IS A FELONY
USE BLACK INK — PLEASE PRINT CLEARLY
AND INCLUDES A CIVIL PENALTY OF UP TO $20,000.
1
Are you a citizen of the United States of America?
Yes
No
2
Check boxes that apply and complete items 3-13
Will you be 18 years of age or over on or before Election Day?
Yes
No
New Registration
Party Affiliation Change
If you checked “no” in response to either of these questions, do not complete this
Name Change
Address Change
form.
3
Last Name (Only)
First Name (Only)
Middle Name (Only)
Jr. Sr. II III IV
4
Home Street Address (No P.O. Box/Business Address. See Instructions.) Apt. #
City
State
Zip Code
5
Mailing Address—If different from above. (P.O. Box or Mail Service Address)
6
Birth Date (M/D/YR)
NV Driver’s License or NV ID Card Number (If neither, last 4 digits of your SSN)
7
Place of Birth(State or Country)
8
9
Telephone No.(Opt.)
10
11 “I swear or affirm I am a U.S. citizen I will be at least 18 years old by the date of
Party Registration—Check Only One Box
the next election I will have continuously resided in Nevada at least 30 days in my
Democratic Party
county and at least 10 days in my precinct before the next election The present
Independent American Party
address listed herein is my sole legal place of residence and I claim no other place
as my legal residence I am not laboring under any felony conviction or other loss
Libertarian Party
of civil rights that would make it unlawful for me to vote. I declare under penalty of
Republican Party
perjury that the foregoing is true and correct.”
Other Party – Write In Below
SIGNATURE OF APPLICANT (REQUIRED)
DATE (REQUIRED)
Nonpartisan (no party affiliation)
___/__ /___
12
Your name and residence address where you were last registered to vote. (Name Used, Street, Apt. #, City, State & Zip Code of Former Residence)
13
Important! If you are assisting a person to register to vote and you are not a field registrar appointed by a County Clerk/Registrar or an employee of a
voter registration agency, you MUST complete the following. Your signature is required. Failure to do so is a felony.
Name
Mailing Address
City/State/Zip Code
Signature
VALIDATING AGENCY USE ONLY. DO NOT WRITE IN THE SHADED AREA BELOW.
CANCELLED
APPLICATION NO. HA
AGENCY
INACTIVE
RECEIVED BY:
FIELD REGISTRAR
AGENCY STAMP HERE
MAIL
PRECINCT
OTHER
Detach Here
Detach Here
Detach Here .
NAME OF PERSON RETAINING
ELECTION OFFICIAL OR AGENCY
VOTER APPLICATION RECEIPT
Contact Information, Address, Telephone, Fax
(Please Retain Receipt)
THIS APPLICATION
If you do not receive a Nevada Voter Registration
Card in the mail within 10 days, please call or visit
AGENCY STAMP OR NAME OF AGENT, ELECTION OFFICIAL OR
PERSON RETAINING APPLICATION
your County Election Department.
PRINT NAME OF PERSON RETAINING FORM
APPLICATION NO. HA
(Revised 8.2012)
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