Texas Voter Registration Application Template
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1Texas Voter Registration Application
For Official Use Only
Prescribed by the Office of the Secretary of State
Please complete sections by printing LEGIBLY. If you have any questions about how to fill out this application, please call your local voter registrar.
Please visit the Texas Secretary of State website, , and for additional election information visit
Este formulario está disponible en español. Favor de llamar a su registrador de votantes local para conseguir una versión en español.
Qualifications
• You must register to vote in the county in which you reside.
• You must be a citizen of the United States.
• You must be at least 17 years and 10 months old to register, and you must be 18 years of age by election Day.
• You must not be finally convicted of a felony, or if you are a felon, you must have completed all of your punishment, including any term of incarceration,
parole, supervision, period of probation, or you must have received a pardon.
• You must not have been determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially mentally
incapacitated without the right to vote.
TheSe QUeSTIoNS MUST Be CoMPLeTeD Before ProCeeDINg (Check one)
1
New Application
Change of Address, Name, or Other Information
Request for a Replacment Card
Are you a United States Citizen?
Yes
No
Will you be 18 years of age on or before election day?
Yes
No
If you checked 'No' in response to either of the above, do not complete this form.
Are you interested in serving as an election worker?
Yes
No
2
First Name
Middle Name
Last Name
Former Name
(If any)
Include Suffix if any (Jr, Sr, III)
(if any)
3
Residence Address:
City
TEXAS
Street Address and Apartment Number. If none, describe
where you live.
(Do not include P.O. Box, Rural Rt. or Business Address)
County
Zip Code
4
Mailing Address:
City
State
Street Address and Apartment Number. (If mail cannot be
delivered to your residence address.)
Zip Code
5
City and County of Former Residence in Texas
6
7
8
Date of Birth: (mm/dd/yyyy)
Gender
Telephone Number (Optional) Include Area Code
(Optional)
(
)
Male
Female
9
Texas Driver's License No. or Texas Personal I.D. No.
If no Texas Driver's License or Personal Identification,
give last 4 digits of your Social Security Number
(Issued by the Department of Public Safety)
xxx-xx-
I have not been issued a Texas Driver's License/Personal Identification Number orSocial Security Number.
I understand that giving false information to procure a voter registration is perjury, and a crime under state and federal law. Conviction
10
of this crime may result in imprisonment up to 180 days, a fine up to $2,000, or both. Please read all three statements to affirm before
signing.
• I am a resident of this county and a U.S. citizen;
• I have not been finally convicted of a felony, or if a felon, I have completed all of my punishment including any term of incarceration, parole,
supervision, period of probation, or I have been pardoned; and
• I have not been determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially
mentally incapacitated without the right to vote.
X
___________________
Date:
Signature of Applicant or Agent and Relationship to Applicant or Printed Name of Applicant if Signed by Witness and Date.
for voLUNTeer DePUTY regISTrar USe oNLY
Deputy Number
Application must be delivered to Voter Registrar no later than 5 days after receipt
Signature of Volunteer Deputy Registrar
Date
regISTraTIoN reCeIPT
Name of Applicant/Applicant's Agent (if applicable)
Receipt No.:
Name of Volunteer Deputy Registrar
Deputy No.:
Signature of Volunteer Deputy Registrar
Date:
.
You should receive your Voter Registration Certificate within 30 days
Please keep this receipt until you receive your Voter Registration Certificate from the voter registrar.
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