Voter Registration Application

1. Check alll boxes that apply:
New Registration Name Change Address Change Signature Update Political Party Affiliation or Non-Affiliation Change

2. Are you a US Citizen?(If No, DO NOT complete this form) Yes No

3. Last Name First Name Middle Name or Initial 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 to affirm that I DO NOT have a NJ Driver's License, MVC Non-driver ID, or Social Security Number"

6. Home Address(DO NOT use PO Box) Apt Municipality County State Zip Code

7. Mailing Address if different from above Apt Municipality County State Zip Code

8. Last Address Registered to Vote(DO NOT use PO Box) Apt Municipality County State Zip Code

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, I do not wish to be affiliated with any political party.

11. Gender: Male Female

Declaration - I swear or affirm that:

• l I am a U.S. Citizen
• l I live at the above address
• l 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
• l 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

If appicant is unable to complter this form, type the name and address of the indivdual who complted this form. Name Date Address

Important Instructions for sections 5, 6 and 10

5) Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not have any of the information required by section 5, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and valid photo ID, or a document with your name and current address on it to avoid having to provide identification at the polling place.
Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers illegally shall be subject to criminal penalties.

6) If you are homeless, you may complete section 6 by providing a contact point or the location where you spend most of your time.

10) You may declare a political party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than 55 days before the primary election in order to vote in the primary election. Completing section 10 is OPTIONAL and will not affect the acceptance of your voter registration application.

Need More Information? Check boxes below if you would like to receive more information about:
voting by mail
becoming a poll worker
polling place accessibility
voting if you have a disavility, including visual impairment
available elction materials in this alternative language:

You can register to vote if:

• You are a United States citizen.
• You are at least 17 years of age.*
• You will be a resident of the State and county 30 days before the election.
• You are NOT currently serving a sentence, probation or parole because of a felony conviction.
*You may register to vote if you are at least 17 years old but cannot vote until reaching the age of 18.

Registration Deadline: 21 days before an election

Your County Commissioner of Registration will notify you if your application is accepted.
If it is not accepted, you will be notified on how to complete and/or correct the application.
Questions? visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837)