Voter Registration Application Form

I am:
Citizenship and Age
Are you a U.S. citizen?  
Will you be at least 18 years of age on or
before the next General Election?
 
Last Name: * Last Name Required
First Name: * First Name Required
Middle Name or Initial:
Jr., II, Etc.:
House Number and Street: * Residential Address Required
Apt. or Lot #:
City or Post Office: * City or Post Office Required
Zip Code: * Zip Code Required
Additional Rural or Mailing Address (if necessary):
County where you live:
BIRTHDATE
Month Day Year
     
YOU MUST CHOOSE ONE OF THE TWO ITEMS LISTED
Drivers License No:  
Where is my Drivers License Number?
Last 4 Digits of SSN:  
 

Phone No. (Voluntary)

ADDRESS CHANGE ONLY - PREVIOUS ADDRESS
Address:
City:
State:
County:


NAME CHANGE ONLY
Former Legal name:



 Please correct the following:
  • * Last Name Required
  • * First Name Required
  • * Residential Address Required
  • * City or Post Office Required
  • * Zip Code Required