Voter Registration Form

Check all items that apply

New Registration Name Change Address Change Signature update Political Party Affiliation or Non Affiliation Change


Enter Personal Information Below
First Name: Last Name: Middle Initial: Suffix:
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 Apartment Municiplaity County State Zip Code
Mailing Address if different from above Apartment Municipality County State Zip Code
Last Address Registered to vote(DO NOT USE PO BOX) Apartment Municipality County State Zip Code
Former Name If Making Name Change a. Day Time Phone Number(Optional)

b. Email Address
Do you wish to Declare a political party affiliation? Yes, the party name is
No, I do not wish to be affiliated with any political party.
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: Sign or mark and date on lines below.

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

    Name_____________________________
    Date_________________________
    Address______________________
    _____________________________