Arkansas Voter Registration Form - Arkansas Secretary Of State
Download a blank fillable Arkansas Voter Registration Form - Arkansas Secretary Of State in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Arkansas Voter Registration Form - Arkansas Secretary Of State with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2PLEASE PRINT AND USE BLACK INK TO COMPLETE
Rev. 6/11
ARKANSAS VOTER REGISTRATION APPLICATION
Check all that apply:
Office Use Only
____ This is a new registration.
____ This is a name change.
____ This is an address change.
Assigned ID
____ This is a party change.
First Name
Middle Name
Last Name
Jr.
Sr.
Mr.
1
Mrs.
Miss
II. III. IV.
Ms.
Address Where You Live (See Section “C” Below)
Apt. or Lot # City/Town
County
State
Zip Code
2
(Rural addresses must draw map.)
Address Where You Receive Mail If Different From Above
Apt. or Lot #
City/Town
County
State Zip Code
3
4
5
6
Home & Work Phone Numbers (Optional)
Party Affiliation (Optional)
Date of Birth
_________/_________/_________
(H)
(W)
8
Month
Day
Year
7
E-mail Address (Optional)
Have you ever voted in a federal election in this State?
Yes
No
Signature of elector - Please sign full name or put mark.
ID Number - Check the applicable box and provide the appropriate number.
9
Arkansas
Driverʼs license number ____________________________________
If you do not have a driverʼs license provide the last 4 digits of social
security number _____________________________
I have neither a driverʼs license nor social security number.
(A) Are you a citizen of the United States of America and an Arkansas resident?
Yes
No
The information I have provided is true to the best of my knowledge. I do not claim the right
to vote in another county or state. If I have provided false information, I may be subject to
(B) Will you be eighteen (18) years of age or older on or before election day?
a fine of up to $10,000 and/or imprisonment of up to 10 years under state and federal laws.
Yes
No
10
(C) Are you presently adjudged mentally incompetent by a court of competent jurisdiction?
Date:
Yes
No
_____________/_____________/_____________
11
(D) Have you ever been convicted of a felony without your sentence having been
Month
Day
Year
If applicant is unable to sign his/her name, provide name, address and
discharged or pardoned?
phone number of the person providing assistance:
Yes
No
Name ________________________ Address: ________________________
If you checked No in response to either questions A or B, do not complete this form.
City:___________________ State:_____ Phone#:_____________________
If you checked Yes in response to either questions C or D, do not complete this form.
Please complete the sections below if:
MAIL REGISTRANTS: PLEASE SEE SECTION D.
• You were previously registered in another county or state, or
Agency Code (For Official Use Only)
• You wish to change the name or address on your current registration.
Previous Last Name
First Name
Jr.
Sr.
Middle Name(s)
Mr.
A
Mrs.
Miss
II. III. IV.
Ms.
Date of Birth
_________/_________/_________
Month
Day
Year
City or Town
State
Zip Code
Previous House Number and Street Name
Apt.or Lot #
B
If you live in a rural area but do not have a house or street number, or if
you have no address, please show on the map where you live.
IDENTIFICATION REQUIREMENTS
• Write in the names of the crossroads (or streets) nearest where you live.
C
• Draw an “X” to show where you live.
IMPORTANT: If your voter registration application
• Use a dot to show any schools, churches, stores or other landmarks near
form is submitted by mail and you are registering for
where you live and write the name of the landmark.
the first time, and you do not have a valid Arkansas
driver's license number or social security
D
number, in order to avoid the additional identification
Example
NORTH
• Grocery
requirements upon voting for the first time you
Store
must submit with the mailed registration form: (a) a
current and valid photo identification; or (b) a copy
Woodchuck Road
• Public School
of a current utility bill, bank statement, government
check, paycheck, or other government document
X
that shows your name and address.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life