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For office use only |
ii |
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Polling
Place |
Date |
Pct |
Ward |
School |
House |
Senate |
Comm |
Urban |
Conserv |
Reg # |
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TO REGISTER: |
All items, except where noted, must be
completed to register to vote. |
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Under
federal and/or state law, all electors must present ID when voting. |
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1. |
Are you a citizen of the United States of
America? |
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Yes |
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No* |
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2. |
Will you be 18 years of age on or before
election day? |
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Yes |
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No* |
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*Note: If you checked 'no' in response to either
of these questions, do not complete |
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this form. |
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3. |
DRIVER'S LICENSE # ___________________________________ |
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(If you do
not have a driver's license number, list the |
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LAST FOUR DIGITS OF SOCIAL SECURITY #
_____________________________ |
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Under
federal law you are required to provide one of the above, unless you do |
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not have either. If you have neither, a unique number will
be assigned to you. |
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4. |
E-mail Address (optional)
______________________________________________________ |
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5. |
NAME |
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(Please print) |
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Last |
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First |
Middle |
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6. |
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___________________________ |
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9. |
TELEPHONE NUMBER |
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7. |
ADDRESS WHERE YOU LIVE* |
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*Precinct is determined by address where you
live. |
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10. |
DATE OF BIRTH |
____/_____/____ |
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Month Day Year |
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(Street, City, Zip OR Sec., Twp. & Range) |
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11. |
PRINT FORMER NAME (if
changed) |
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8. |
MAILING ADDRESS (If
different than #7) |
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12. |
PLACE LAST REGISTERED |
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CITY |
COUNTY STATE |
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13. |
VOTER DECLARATION |
(Read and sign below) |
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I swear/affirm that: a) I am a U.S. citizen; b) I will be at least 18 years old on or
before the next election; c) I will |
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have lived in this county for at least 30 days
before the next election; d) I am
neither in a penal institution for a |
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felony conviction nor found of unsound mind by
a court; e) If I do not now meet these
qualifications, I will by the next |
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election; and f) I have provided true
information, to the best of my knowledge under penalty of perjury. If I have |
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given false information, I may be subject to a
fine or imprisonment or both under Federal or State laws. |
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14. |
SIGNATURE_______________________________________DATE_________________ |
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