| 1. | Check boxes that apply |
New Registration
Adress Change
Political Party Affiliation Change Name Change Signature Update |
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| 2. | Are you a US citizen Yes No |
Are you atleast 17 years old? Yes No |
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| 3. |
Last Name |
First Name |
Middle Name & Suffix / |
4. |
Date of birth / / |
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| 5. |
Drivers Licence Number - - |
Last 4 digits of SSN(If no licence) |
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| 6. |
Home Adress(P.O. Boxes not valid)
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Apt. |
Municipality |
Zipcode |
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| 7. |
Mailing Adress(if different from above)
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Apt. |
Municipality |
Zipcode |
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| 8. |
Last Adress Registered to Vote
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Apt. |
Municipality |
Zipcode |
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| 9. |
Former Name(If Making Name Change) |
a. Day Phone Number (optional): +1()-
-
b. E-Mail Adress (optional): |
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| 10. | Do you wish to declare a political party affiliation?(optional) |
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| 11. | Gender: Female Male |
Declaration- I swear that: I am a U.S. Citizen I live at the above address I am at least 17 years old, and understand that I may not vote until reachingthe 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 |
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| 12. |
Signature: Enter your eletronic signiture by using the format "/s/ First Last" and date X Date:/ / |
If applicant is unable to complete this form, print the name and address of the individual who completed this form. Name: Date:/ / Adress: |
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