1. Check boxes that apply:
    • New Registration
    • Address Change
    • Political Party Affiliation or Non-Affiliation Change
    • Name Change
    • Signature Update
  2. Are you a U.S. Citizen?
    Are you at least 17 years of age? (If No, DO NOT complete this form)

  3. Please fill in the following fields:

    First Name:

    Middle Name or Initial:

    Last Name:

    Suffix (Jr., Sr., III):

  4. Date of Birth:
  5. NJ Driver's License Number or MVC Non-Driver ID Number:

    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.

    "I swear or affirm that I DO NOT have a NJ Driver's License, MVC Non-driver ID or a Social Security Number."

  6. Home Address: Apt. Municipality: State: Zip Code:
  7. Mailing Address if different from above: Apt. Municipality: State: Zip Code:
  8. Last Address Registered to Vote: (Do not use PO Box) Apt. Municipality: State: Zip Code:
    • Former Name if Making Name Change:
    • Day Phone Number (Optional)
    • Email-Address (Optional)
    • Do you wish to declare a political party affiliation?
    • Gender:
Declaration - I swear or affirm that:
  • I am a U.S. Citizen
  • I live at the above address
  • I am at least 17 years old, and under-stand that I may not vote until reaching the age of 18.
  • I will have resided in the State and county at least 30 days before the next election
  • I am not on parole, probation or serving a sentence due to a conviction for an indictable offense under any federal or state laws
  • 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
  • Please electronically sign this form: Today's date:
  • If applicant is unable to complete this form, print the name and address of individual who completed this form.
  • Please electronically sign this form: Today's date: Address: