Political Party Affiliation or Non-Affiliation Change
Name Change
Signature Update
Are you a U.S. Citizen?
Are you at least 17 years of age? (If No, DO NOT complete this form)
Please fill in the following fields:
First Name:
Middle Name or Initial:
Last Name:
Suffix (Jr., Sr., III):
Date of Birth:
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."
Home Address:
Apt.
Municipality:
State:
Zip Code:
Mailing Address if different from above:
Apt.
Municipality:
State:
Zip Code:
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:
