Voter Registration

Personal Information
Full Legal Name Here	Gender (Check One): Female Male
Full Legal Name Here	Gender (Check One): Female Male	Date of Birth
Reason for Application
Check Applicable Reason(s): New Registration Name Change Address Change Political Party Affiliation or Non-Affliation Change	Are you an American Citizen?: Yes No- (if no, DO NOT complete this form)	Are you 17 years of age?: Yes No - (if no, DO NOT complete this form)
	NJ Driver's License or MVC ID Number:	Do you wish to declare a political party affiliation? (optional): Yes No - I do not wish to be affiliated with a political party.
Additonal Information
Home Address:	Last Address Registered to Vote, if different from home address: Address:
Former Name if Making a Name Change:	Contact Information: Day Phone Number (optional):	E-mail (Optional):
Declaration
I swear and affirm 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 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 federak or state laws I understand that any false or fraudulent registration may be 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

Personal Information