New Jersey
Voter Registration Application

Please check all the boxes that apply:

New Registration Name Change Address Change Signature Update Political Party / Non-affiliation Change

Residency

Are you a resident of New Jersey? Yes No

(If No, please DO NOT complete this form)

Citizenship

Are you a United States Citizen? Yes No

(If No, please DO NOT complete this form)

Age

Are you 17 years or older? Yes No

Date of Birth:

(If No, please DO NOT complete this form)

Gender female male

Identification

Do you have a valid NJ Driver's License or Non-Driver ID Number? Yes No

NJ Driver's License or MVC Non-driver ID Number

If No, Please enter the last 4 Digits of Social Security

"I swear or affirm that I DO NOT have a NJ Driver's License, MVC Non-driver ID or a Social Security Number"

Declaration

I swear or affirm that:

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

Personal Information

Name

Former Name (if name change)

Address Home Address

Mailing Address (if different from address above)

Additional Information

Day Phone Number (optional)

Email Address (optional)

Do you wish to declare a political affiliation? (optional)

Yes

Applicant Signature

Signature: Date:

Note: If you are filling out this form for an applicant because he/she is unable to do so, please place a check in the box

Please fill in your information (not the applicant's) down below:

Signature: Date: