Middlesex County Voter Registration

1. Check boxes that apply		New Registration		Name Change	Address Change
		Signature Update		Political Party Affiliation/Non-Affiliation Change
2. Are you a US Citizen? YES NO			Are you at least 17 years of age? YES NO
3. Last Name		First Name		Middle initial	suffix
4. Date of Birth
5. Drivers liscense
6. Home Address	Apt.	Municipality	County	State	Zipcode
7. Mailing Address	Apt.	Municipality	County	State	Zipcode
8. Last Address registered to vote	Apt.	Municipality	County	State	Zipcode
9. Former Name			Day phone number
			email address
10.Do you wish to declare a political party affiliation YES and the party is NO I do not wish to affilliated with any political party.
11. Gender Male Female	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
Signature Are you lying? YES NO				Name
				Date
				Address