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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>
<style>
.header h1{
margin-left: 10px;
display:inline-block;
margin-bottom: -3em;
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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{
margin-left: 10em;
margin-top: 0px;
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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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