Fillable Form Dl-14c - 2011 Application For Texas Election Certificate printable pdf download

Form Dl-14c - 2011 Application For Texas Election Certificate

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DL-‐14C ( Dec 2 011)

APPLICATION F OR T EXAS E LECTION C ERTIFICATE

FOR D EPARTMENT U SE

FOR E LECTION P URPOSES O NLY; C ANNOT B E U SED A S A N I DENTIFICATION C ARD

ONLY

ASSIGNED # _ ___________

NOTICE: A ll i nformation o n t his a pplication m ust b e c ompleted i n I NK.

APPLICANT I NFORMATION

CONTACT I NFORMATION

LAST N AME:

HOME P HONE:

FIRST N AME:

OTHER P HONE:

MIDDLE N AME:

EMAIL:

SUFFIX:

MAIDEN N AME:

ADDRESS I NFORMATION

RESIDENCE A DDRESS:

DATE O F B IRTH ( mm/dd/yyyy):

-‐

SSN:

-‐

CITY:

STATE:

SEX: ( Circle O ne)

Male

Female

ZIP C ODE:

COUNTY:

EYE C OLOR:

HAIR C OLOR:

RACE:

MAILING A DDRESS:

HEIGHT: f t.

in.

WEIGHT: l bs.

CITY:

STATE:

UNITED S TATES C ITIZEN: yes

ZIP C ODE:

COUNTY:

If y ou a re n ot a U S c itizen, y ou a re n ot e ligible f or a n E lection C ertificate

PLACE O F B IRTH: C ITY:

COUNTY:

STATE:

COUNTRY:

FATHER’S L AST N AME:

MOTHER’S M AIDEN N AME:

INFORMATION R EQUIRED F ROM A LL A PPLICANTS:

YES NO

Are y ou p resenting a v oter r egistration c ard t oday?

If n ot, a re y ou r egistering t o v ote?

Do y ou h ave a T exas d river l icense o r l earner l icense ( unexpired, o r e xpired f or n o m ore t han 6 0 d ays)?

Do y ou h ave a T exas i dentification c ard ( unexpired, o r e xpired f or n o m ore t han 6 0 d ays)?

Do y ou h ave a T exas c oncealed h andgun l icense ( unexpired, o r e xpired f or n o m ore t han 6 0 d ays)?

Do y ou h ave a U S p assport ( unexpired, o r e xpired f or n o m ore t han 6 0 d ays)?

Do y ou h ave a U S c itizenship c ertificate t hat c ontains y our p hotograph?

Do y ou h ave a U S m ilitary i dentification c ard t hat c ontains y our p hotograph ( unexpired, o r e xpired f or n o m ore t han 6 0 d ays)?

If a nswering “ yes” t o q uestions 3 t hrough 8 , y ou a re n ot e ligible t o r eceive a T exas E lection C ertificate.

CERTIFICATION

I d o s olemnly s wear, a ffirm, o r c ertify t hat I a m t he p erson n amed h erein a nd t hat t he s tatements o n t his a pplication a re t rue a nd c orrect.

X_________________________________________________________

__________________________

Date:

VERIFICATION

Sworn t o a nd s ubscribed b efore m e t his _ ________ d ay o f _ ______________________________, _ _________

Notary P ublic i n a nd f or t he S tate o f T exas o r A uthorized O fficer

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