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. Home Address: Apt. Municipality: State: Zip Code:

  8. Home Address: Apt. Municipality: State: Zip Code:

  9. Former Name if Making Name Change:

    • Day Phone Number (Optional)

    • Email-Address (Optional)

    10. Do you wish to declare a political party affiliation?
    11. Gender:
  • Please electronically sign this form: Today's date: