Virginia Voter Registration Application printable pdf download

Virginia Voter Registration Application

Use blue or black ink

Starred (*) items are required. If you do not complete all of the items that are marked with *, your application may be denied (See instructions on reverse side).

YES

Date of

Full social

I am a citizen of the

security

Gender

birth

number

United States of America.

No SSN was ever issued.

Jr. Sr. II III IV

(Circle if applicable)

Last name

None

Middle name

First name

Residence address

Apt #

(May not be a P.O. Box)

ZIP

City/Town

E-mail

Phone

Have you ever been convicted of a felony or

judged mentally incapacitated and disqualifi ed to vote? .........

YES

If YES, has your right to vote been restored? .......

YES

I am an active-duty uniformed services member, spouse or dependent; or an overseas citizen.

I am providing a mailing address (below) because my residence address is not serviced by the U.S. Postal Service or I am homeless.

I am providing a Virginia P.O. Box (below) to protect my residence address from public disclosure because:

I am an active or retired law enforcement offi cer, judge, U.S. or Virginia Attorney General attorney

I have a court issued protective order for my benefi t

I have evidence of fi ling a complaint with law enforcement that either I or a household member is in fear for personal safety

from another person who has threatened or stalked either me or a household member

I am a participant in the Virginia Attorney General’s Address Confi dentiality Program

My mailing address

(Complete only if you have checked a box in this section)

I am currently registered to vote in another state:

(Indicate state of previous registration)

I am interested in being an Oﬃ cer of Election (poll worker) on Election Day.

Please send me information.

AFFIRMATION: I swear affirm, under felony penalty for making willfully false material statements or entries, that the information provided

on this form is true. I authorize the cancellation of my current registration and I have read the Privacy Act Notice.

Today’s date:

* Signature

By checking this box, I affi rm both that I am an individual with physical disabilities and the Affi rmation Statement above. Pursuant to

Article II, § 2 of the Constitution of Virginia, individuals with physical disabilities are not required to sign the application for voter registrations.

Virginia Voter Registration Application Receipt

The application collector must submit your

completed application within 10 days or by the

deadline to register for the next election, whichever

Date application received

comes fi rst. You can check your voter registration

status online at elections.virginia.gov/register .

If you do not receive confi rmation of your voter

registration status within 30 days, contact your local

voter registrar or the Virginia Department of Elections.

Thank you for applying

Name, phone and e-mail of offi ce, group or individual