Voter Registration Form

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_________________