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