Fillable Kansas Voter Registration Application printable pdf download

For further information, contact the Office of the Secretary of State,

Kansas Voter Registration Instructions

1-800-262-VOTE (8683) V/TTY. This form is available at

You can use this application to:

Identification number requirements

•

Enter your current Kansas driver’s license number or nondriver’s identifica-

•

change your name, address, or affiliation with a political party

tion card number. If you do not have either one, enter the last four digits

of your Social Security number. If you do not have any of these numbers,

To register to vote, you must:

write “none” in the box. The number will be used for administrative pur-

poses only and will not be disclosed to the public. K.S.A. 25-2309

•

be a U.S. citizen and a resident of the state of Kansas.

Proof of U.S. citizenship

•

have reached the age of 18 years before the next election.

•

have received final discharge from imprisonment, parole, or condi-

tional release if convicted of a felony.

If you are registering for the first time in Kansas, you must submit

•

have abandoned your former residence and/or name.

proof of United States citizenship. You may provide a copy on paper or

electronically, or you may show the document to an election officer or

How to register to vote:

official registrar. The following is a partial list of acceptable documents:

•

Birth certificate that verifies U.S. citizenship

•

Return your completed application to your county. Addresses are on

•

U.S. passport (may be expired)

the back of this application. Your county election officer will mail you a

•

U.S. naturalization documents or the number of the certificate of

notice when your application has been processed.

naturalization

•

Voter registration closes 21 days before any election. In order to be

•

Bureau of Indian Affairs card number, tribal treaty number or tribal

eligible to vote in that election, your application must be postmarked

enrollment number

on or before that date.

•

U.S. hospital record of birth indicating place of birth in the U.S.

•

If you decline to register to vote, that fact will remain confidential and

•

U.S. military record of service showing the applicant’s name and U.S.

will be used for voter registration purposes only. If you do register to

birthplace

vote, the office where you apply will be kept confidential and will be

used for voter registration purposes only.

For a list of acceptable documents, visit If you do not have any

•

If this form is incomplete, it may be rejected.

of the documents, you may appeal to the state election board.

Rev. 12/12/12 tc

Print in blue or black ink, fold on the center line, seal, and return.

Warning: If you submit a false voter registration application,

Kansas Voter Registration Application

you may be convicted and sentenced to up to 17 months in prison.

Qualifications:

If you mark “no” in response to either Question 1 or 2, do

not

complete this form.

○

1. Are you a citizen of the United States of America?

Yes

○

2. Will you be 18 years of age on or before Election Day?

Yes

○

Last Name (please print)

First Name

Middle

Jr. Sr. II III

Male

○

Female

Residential Address (include apt. or space number)

City

County

Zip

Mailing Address (if different than residential address)

City

Zip

Date Residence Established (MM/DD/YY)

Birth Date (MM/DD/YY)

Daytime Phone Number (if available)

Naturalization Number (if applicable)

Driver’s License Number or Last 4 Social Security (see instructions)

○

Party Affiliation: Choose one of the following:

Democratic

Republican

Libertarian

Not affiliated with a party

Previous Name

Previous Residential Address (Street, City, State, Zip, County)

Complete if previously

registered (please print)

Signature: I swear or affirm that I am a citizen of the United States and a Kansas resident, that I will be 18 years old before the next election, that if convicted of a felony, I

have had my civil rights restored, that I have abandoned my former residence and/or other name, and that I have told the truth on this application.

Signature

Date (MM/DD/YY)

For office use only: Ward ______________________ Pct. ______________________ School Dist. ______________________ Member Dist. ______________________

Sen. ________________ Rep. ________________ CoComm ________________ Section ________________ Township ________________ Range _________________

Kansas Voter Registration Application

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