Virginia Voter Registration Application Form Page 3
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4Mail your completed form to: Alexandria General Registrar; 132 N. Royal Street #100; Alexandria VA 22314
Virginia Voter Registration Application Form
Use this form to register to vote in Virginia or report a change in name or address. If you are already registered with your current name
and address, you do not need to re-register.
To register to vote in
·Be a United States citizen
·Have had your voting rights restored if you have ever been convicted of a felony
Virginia, you must:
·Be a resident of Virginia
·Have had your capacity restored if you have ever been declared mentally incapacitated in
a Circuit Court
·Be 18 years old by the next general election
Identification Requirement
For Registration: If you are registering for the first time by mail, federal law (the Help America Vote Act) requires you to provide identification the first time you
vote in a federal election. Please enclose a copy of one of the following documents that shows your name and address with your application: (1) current and
valid photo ID, (2) current utility bill, (3) bank statement, (4) government check, (5) paycheck, or (6) other government document. If eligible to vote absentee by
mail, your mailed absentee ballot will not be counted unless the required identification has been provided to your local electoral board no later than noon on the
Friday following the election.
For Voting: Virginia law requires you also to provide photo identification when you vote in person. An information card or other correspondence confirming your
registration does not qualify as photo identification. For information on types of qualified photo identification, or how to obtain a Voter Photo Identification card,
please visit or call toll free 1-800-552-9745 (TTY: 1-800-260-3466) .
Starred (*) items are required. If you do not complete all of the items that are marked with *, your application may be denied. Once your local registrar approves
your application, you will receive confirmation by mail.
1
*
Are you a citizen of the United States
*
Will you be at least 18 years of age on or before
If you checked “NO” in response to either of
of America?
YES
NO
the next General Election day?
YES
NO
these questions, do not complete this form.
M
M
D
D
Y
Y
Y
Y
2
-
-
-
-
Male
Female
/
/
Daytime Telephone Number
*
Social Security Number
*
Gender
*
Date of Birth
None
None
Last Name
First Name
Full Middle or Maiden Name
Suffix (Jr., Sr., III, Etc.)
*
*
*
*
3
*
Residence (Permanent) Home Address
Apt/Unit/Lot/Rm/Ste
City/Town
Zip Code
E-mail address
If Rural Address or Homeless, please describe where you reside
City or
County:
Mailing Address (if different)/Virginia P.O.Box or Uniformed Service Address, if applicable (include Zip Code)
Name of City or County of Residence
4
*Have you ever been convicted of a felony?
YES
NO State where convicted
M
M
D
D
Y
Y
Y
Y
If YES, have your voting rights been restored?
YES
NO If YES, when restored?
/
/
Have you ever been judged mentally incapacitated?
YES
NO
5
*
M
M
D
D
Y
Y
Y
Y
If YES, has court restored you to capacity?
YES
NO If YES, when restored?
/
/
Registration Statement: I swear/affirm, under felony penalty for making willfully false material statements or entries, that the information
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provided on this form is true. I authorize the cancellation (entered in Box 7 below) of my current registration and I have read the Privacy
Act Notice on the front of this form.
M
M
D
D
Y
Y
Y
Y
* Signature (or mark if unable to sign)
/
/
Check if you have a disability that
If applicant is unable to sign due to a physical disability, write the name/address of person who assisted. (Required).
requires someone to assist you in order to
vote.
Protected Voter Code if applicable. See instructions.
I’m interested in being an Election Official on Election Day. Please send me information.
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*Previous Voter Registration Information–Commonwealth of Virginia
No, I am not currently registered to vote in Virginia or another state.
Yes, I am registered to vote at another address in Virginia or in another state. If YES, the information below must be completed:
M
M
D
D
Y
Y
Y
Y
-
-
/
/
Date of Birth
Social Security Number
Full Name as Registered
(last 4 digits required)
Address at which you were previously registered to vote
City/Town
State
Zip Code
City/County/Town of Residence (if applicable). This cancellation information will be sent to the county or city and state you entered above.
SBE-416.2 Rev. 7/14
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