New Jersey
Voter Registration Application

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?

Yes No
(If No, DO NOT complete this form)

Are you at least 17 years of age?

Yes No
(If No, DO NOT complete this form)

3:)Full Name

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

DO NOT use PO Box

7:) Mailing Address if different from above

8:) Last Address Registered to Vote

DO NOT use PO Box

9:) Former Name if Making Name Change


a. Day Phone Number (Optional)
b. E-Mail Address (Optional)

10:) Do you wish to declare a political party affiliation? (Optional)

Yes, the party name is
No

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:
If applicant is unable to complete this form, print the name and address of individual who completed this form.