Voter Registration Form

Purpose: This official form is used to register eligible citizens to vote in local, state, or national elections. Ensure all provided information is accurate and complete. Submit the completed form to the appropriate election authority.

Personal Information

Full Name: {firstName} {middleName} {lastName}

Date of Birth: {dateOfBirth}

Gender: {gender}

Phone Number: {phoneNumber}

Email Address: {email}

Residential Address

Street Address: {streetAddress}

City: {city}

State: {state}

ZIP Code: {zipCode}

County: {county}

Mailing Address

Street Address: {mailStreetAddress}

City: {mailCity}

State: {mailState}

ZIP Code: {mailZipCode}

Eligibility Confirmation

• I am a citizen of the United States: {isCitizen}
• I will be at least 18 years old on or before election day: {isEighteenOrOlder}
• I am not currently incarcerated for a felony offense: {notIncarcerated}

Political Party Affiliation

Please select your party affiliation (if any): {partyAffiliation}

{#previousRegistration}

Previous Voter Registration

Previously Registered Name: {previousName}

Previous Address: {previousAddress}

Previous County/State: {previousCounty}, {previousState}

{/previousRegistration}

Assistance Information

{#requiresAssistance}

Type of Assistance Required: {assistanceType}

Name of Assistant (if applicable): {assistantName}

Relationship to Applicant: {assistantRelationship}

{/requiresAssistance}

Optional: Voting Preferences

{#votingPreferences}

• {preference}

{/votingPreferences}

Signature

By signing below, I affirm that the above information is true and complete. I understand that providing false information may be punishable by law.

Applicant Signature: ___________________________

Date: {dateSigned}

{#witnessRequired}

Witness Information

Witness Name: {witnessName}

Witness Signature: ___________________________

Date: {witnessDate}

{/witnessRequired}