Voter Registration Application

Please print clearly in ink. All information is required unless marked optional.
1   Check boxes that apply:
New Registration    Address Change    Name Change   
Signature Update    Address Change    Political Party Affiliation or Non-Affiliation Change
2   Are you a U.S. Citizen?   Yes   No   (If No, DO NOT complete this form) Are you a at least 17 years of age?   Yes   No
(If No, DO NOT complete this form)
3   Last Name

First Name
 Middle Name or Initial
Suffix (Jr., Sr., III)
4   Date of Birth Please select a Pokemon
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 P.O. Box)
 Apt.
 Municipality
 County
 State
 Zipcode
7   Mailing Address (if different from above)
 Apt.
 Municipality
 County
 State
 Zipcode
8   Last Address Registered to Vote (Do NOT use P.O. Box)
 Apt.
 Municipality
 County
 State
 Zipcode
9   Former Name if Making Name Change  Gender
Male
Female 		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
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 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 federal or state laws
  • I understand that any false or fradulent 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
View State and Federal rules about electronic signatures.
X    Date 		If applicant is unable to complete this form, print the name and address of individual who completed this form.
Name     Date     Address  

Important Instructions for sections 5, 6, and 10

5) Registrants who are submitting this formby 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 verifid, 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 Con dential 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 area previously affiliated voter who wants to change political party affiliation or become unaf liated, 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.