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  <div class= "header">

  <h1>New Jersey </br> <b>Voter Registration Application</b> </h1> 

  <img src="http://nclrights.files.wordpress.com/2010/01/seal-of-nj.jpg" alt="" />

  <p><font size="2"> <i>Please print clearly in ink. All information is required unless marked optional.</i> </font>

  </p>

  </div>

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  .header img {

    float: left;

    height: 90px;

    width: 90px;

    margin-top: 1.2em;

    margin-left: 3.5em;

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  .header p{

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  <fieldset>

  <!-- 1 -->  

  <legend>1. Check boxes that apply </legend>

    <leabel for="optA">

      <input type="radio" value="A" name="radio" id="optA"> New Registration

    </label>

  <label for="optB">

    <input type="radio" value="B" name="radio" id="optB" unchecked> Name Change

    </label>

    <label for="optC">

      <input type="radio" value="C" name="radio" id="optC"> Address Change

    </label>

  <label for="optD">

      <input type="radio" value="B" name="radio" id="optD" unchecked> Signature Update

    </label>

    <label for="optE">

      <input type="radio" value="C" name="radio" id="optE"> Political Party Affiliation or Non-Affiliation Change

    </label>

  </fieldset>

  <p></p> 

  <!-- 2 -->  

  <fieldset>

    <legend>2. </legend> 

    <fieldset>

      <legend>Are you a U.S. Citizen? <i>(If No, DO NOT complete this form)</i></legend>

      <label for="optA">

        <input type="radio" value="A" name="radio2" id="optA"> Yes

      </label>

    <label for="optB">

        <input type="radio" value="A" name="radio2" id="optB"> No

      </label>  

    </fieldset>  

    <p></p>

  <fieldset>

    <legend>Are you at least 17 years of age? <i>(If No, DO NOT complete this form)</i></legend>

    <label for="optA">

      <input type="radio" value="A" name="radio2b" id="optA"> Yes

    </label>

  <label for="optB">

    <input type="radio" value="B" name="radio2b" id="optB" unchecked> No

    </label>   

  </fieldset>

 </fieldset>

  <p></p>

  <!--3 -->

 <fieldset>

   <legend>3.</legend>

<input type="text" placeholder="First Name"/>

<input type="text" placeholder="Last Name"/>

   <input type="text" placeholder="Middle Name or Initial"/>

<input type="text" placeholder="Suffix (Jr., Sr., III)"/>

 </fieldset>

  <p></p>

 <fieldset>

  <!-- 4 -->

<legend>4. Date of Birth</legend>

  <div>

    <input type="date" name="date">

  </div>

 </fieldset>

  <p></p>

    <fieldset>

<legend>5. </legend>   

      <fieldset>

        <legend>NJ Driver’s License Number or MVC Non-driver ID Number</legend>

        <div>

    <input type="number" name="number">

    </div>

        <div>

    <input type="checkbox" name="checkbox" unchecked ><font size= "2">“I swear or affirm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”</font> 

</div>

      </fieldset>

      <p></p>

      <fieldset>

      <legend><font size= "2">If you DO NOT have a NJ Driver’s License or MVC Non-Driver

ID, provide the last 4 digits of your Social Security Number</font></legend>

        <div>

    <input type="number" name="number">

    </div>

      </fieldset>

    </fieldset>

  <p></p>

    <fieldset>

<legend>6. Home Address <font size="1"> <i>(DO NOT use PO Box)</i></font></legend>

  <div>

    <input type="text" name="text" placeholder="Home Address">

        <input type="number" name="text" placeholder="Apt.">

        <input type="text" name="text" placeholder="Municipality">

        <input type="text" name="text" placeholder="County">

    <select name="select">

<option value="pancakes">NJ</option>

</select>

        <input type="number" name="text" placeholder="Zip Code">

</div>

    </fieldset>

  <p></p>

    <fieldset>

<legend>7. Mailing Address if different from above</legend>

      <div>

    <input type="text" name="text" placeholder="Mailing Address">

        <input type="number" name="text" placeholder="Apt.">

        <input type="text" name="text" placeholder="Municipality">

        <input type="text" name="text" placeholder="County">

    <select name="select">

<option value="pancakes">NJ</option>

</select>

        <input type="number" name="text" placeholder="Zip Code">

</div>

    </fieldset>

  <p></p>

    <fieldset>

<legend>8. Last Address Registered to Vote <font size="1"> <i>(DO NOT use PO Box)</i></font></legend>

      <div>

    <input type="text" name="text" placeholder="Last Address ">

        <input type="number" name="text" placeholder="Apt.">

        <input type="text" name="text" placeholder="Municipality">

        <input type="text" name="text" placeholder="County">

    <select name="select">

<option value="pancakes">NJ</option>

</select>

        <input type="number" name="text" placeholder="Zip Code">

</div>

    </fieldset>

  <p></p>

    <fieldset>

<legend>9. Former Name if Making Name Change</legend>

         <input type="text" name="text" placeholder="Former Name">


    <input type="tel" name="tel" placeholder="Phone No. (Optional)"> 

    <input type="email" name="email" placeholder="Email (Optional)">

    </fieldset>

  <p></p>

    <fieldset>

<legend>10. Do you wish to declare a political party affiliation? <font size="2">(Optional)</font></legend>

      <label for="optA">

    <input type="radio" value="A" name="radio10" id="optA"> Yes, the party name is <input type="text"/>

    </label>

<label for="optB">

    <input type="radio" value="B" name="radio10" id="optB" unchecked> No, I do not wish to be affiliated with any political party

    </label>

    </fieldset>

  <p></p>

    <fieldset>

<legend>11.</legend>

      <fieldset>

      <legend>Gender</legend>

        <label for="optA">

<input type="radio" value="A" name="radio11" id="optA"> Female

    </label>

<label for="optB">

    <input type="radio" value="B" name="radio11" id="optB" unchecked> Male

    </label>

      </fieldset>

      <p></p>

    <fieldset>

      <div>

  <font size="2"> Declaration - I swear or affirm that:


    <ul>

      <li>l I am a U.S. Citizen</li>

      <li> I live at the above address</li>

      <li> I am at least 17 years old, and under-

 stand that I may not vote until reaching

 the age of 18.</li>

      <li> I will have resided in the State and county

at least 30 days before the next election</li>

      <li> I am not on parole, probation or serving a

sentence due to a conviction for an indictable

offense under any federal or state laws</li>

      <li>I understand that any false or

fraudulent registration may subject

me to a fine of up to $15,000,

imprisonment up to 5 years, or

both pursuant to R.S. 19:34-1</li>

    </ul></font>

    </div>

      <legend>Signature: Sign or mark and date on lines below</legend>

        <input type="text" name="text" placeholder="eSign: Print Your Name">

      <input type="date" name="text" placeholder="Date">

      </fieldset>

  <p></p>

<fieldset>

  <legend><font size="2"> If applicant is unable to complete this form, print the

name and address of individual who completed this form</font></legend>

          <input type="text" name="text" placeholder="Name">

        <input type="date" name="text" placeholder="Date">

        <input type="text" name="text" placeholder="Address">

  </fieldset>

  

    </fieldset>


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