Check boxes that apply:
Name Registration
Name Change
Address Change
Signature Update
Political Party Affiliation or Non-Affiliation Change
Are you a U.S. Citizen?
Yes
No
Are you of 17 years of age? (If no, DO NOT complete this form):
Yes
No
Last Name:
First Name:
Middle Name:
Suffix:
Date of Birth:
Gender:
Male
Female
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:
Home Address (Do NOT use PO Box):
Apt:
Municipality:
County:
State:
Zip Code:
Mailing Address if different from above:
Apt:
Municipality:
County:
Zip Code:
Last Address Registered to Vote (Do NOT use PO Box):
Apt:
Municipality:
County:
Zip Code:
Former Name if Making Name Change
Day Phone Number (Optional)
E-Mail Address (Optional)
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.
Declaration: 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 law.
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.
Do you accept this declaration?
Yes
No