Pennsylvania Voter Registration Application Page 3
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4Pennsylvania Voter Registration Application
Use blue or black ink
Last name
Jr
Sr
II
III
IV
(circle if applicable)
Print your name
1
First name
Middle name or initial
Eligibility
Are you a citizen of the U.S.?
Yes
No
If you answer “No” to
2
Will you be 18 years or older
either question, you cannot
Yes
No
on or before election day?
register to vote.
New registration
Change of name
Change of address
Reason
3
Change of party
Federal or State employee registering in county of last residence
About you
Birth date
Race (optional)
Sex
M
F
/
/
M
M
D
D
Y
Y
Y
Y
Phone and email are optional
4
and used if information is
Phone
Email
–
–
missing on this form.
Address (not P.O. Box)
Apt. number
Your address
PA
City/Town
State
Zip Code
If you do not have a street address
5
or a permanent residence, or are a
Municipality
County
student, see the instructions.
I do not have a street address or permanent residence (use map on back)
Address or P.O. Box
Same as above
The address where
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you receive mail
City/Town
State
Zip Code
Identification
PennDOT driver’s license or ID card number
If you have a PennDOT number
you must use it. If not please
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Last four digits of your Social Security number
x x x – x x –
provide the last four digits of
your Social Security number.
I do not have a Pennsylvania driver’s license or a Social Security number
See Verifying your identity.
Political party
To vote in a primary, you
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Democratic
Republican
Other:
None
must register with either the
Democratic or Republican party.
I require help to vote. I need this kind of assistance
Voting assistance
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My preferred language
If your name
Name on previous registration
or address has
changed
10
Full previous address and county
Skip if this is the first time
PA Voter No. (if available)
Year
–
you are registering to vote.
I declare that
Signature or mark
• I am a United States citizen and will have been a citizen
for at least 1 month on the day of the next election.
• I will be at least 18 years old on the
day of the next election.
• I will have lived at the address in Section 5
Declaration
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for at least 30 days before the election.
• I am legally qualified to vote.
Print
I affirm that this information is true. I understand that
your name
this declaration is the same as an affidavit, and, if this
information is not true, I can be convicted of perjury, and
Today’s date
/
/
fined up to $15,000, jailed for up to 7 years, or both.
M
M
D
D
Y
Y
Y
Y
Name of assistant
Help with this form
Fill in if someone helped you
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Address
with this form or witnessed you
make a mark for your signature.
Phone
Signature of assistant
DSBE-6002/15
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