New York State Voter Registration Form Register to vote Send or deliver this form Verifying your identity Fill out the form below and send it to your We’ll try to check your identity before Election With this form, you register to vote in elections in county’s address on the back of this form, Day, through the DMV number (driver’s license New York State. You can also use this form to: or take this form to the office of your County number or non-driver ID number), or the last Board of Elections. four digits of your social security number, • change the name or address which you’ll fill in below. on your voter registration Mail or deliver this form at least 25 days before • become a member of a political party the election you want to vote in. Your county will If you do not have a DMV or social security notify you that you are registered to vote. number, you may use a valid photo ID, a current • change your party membership utility bill, bank statement, paycheck, government Questions? check or some other government document that To register you must: shows your name and address. You may include Call your County Board of Elections • be a US citizen; a copy of one of those types of ID with this form— listed on the back of this form or be sure to tape the sides of the form closed. • be 18 years old by the end of this year; 1-800-FOR-VOTE (TDD/TTY Dial 711) • not be in prison or on parole If we are unable to verify your identity before for a felony conviction; Find answers or tools on our website Election Day, you will be asked for ID when • not claim the right to vote elsewhere. www.elections.state.ny.us you vote for the first time.

Información en español: si le interesa obtener este 中文資料:若您有興趣索取中文資料表格, 한국어: 한국어 양식을 원하시면 formulario en español, llame al 1-800-367-8683 請電: 1-800-367-8683 1-800-367-8683 으로 전화 하십시오.

It is a crime to procure a false registration or to furnish false information to the Board of Elections. Please print in blue or black ink.

Are you a citizen of the U.S.? Yes No For board use only 1 If you answer No, you cannot register to vote. Qualifications Will you be 18 years of age or 2 older on or before election day? Yes No If you answer No, you cannot register to vote unless you will be 18 by the end of the year.

Last name Suffix

Your name 3 Middle Initial First name

4 Birth date M M / D D / Y Y Y Y 5 Sex M F More information 6 Telephone (optional) – –

Address (not P.O. box)

The address Apt. Number Zip code 7 where you live City/Town/Village New York State County

Address or P.O. box The address where you receive mail 8 P.O. Box Zip code Skip if same as above City/Town/Village

Voting history 9 Have you voted before? Yes No 10 What year?

Voting information Your name was that has changed 11 Your address was Skip if this has not changed or you have not voted before Your previous state or New York State County was

Identification New York State DMV number You must make 1 selection 12 Last four digits of your Social Security number x x x – x x – For questions, please refer to Verifying your identity above. I do not have a New York State driver’s license or a Social Security number.

Political party Democratic party Affidavit: I swear or affirm that You must make 1 selection Republican party • I am a citizen of the United States. • I will have lived in the county, city or village Conservative party To vote in a primary election, for at least 30 days before the election. you must be enrolled in one Working Families party • I meet all requirements to register of these listed parties — 13 to vote in New York State. except the Independence Party, Independence party • This is my signature or mark in the box below. which permits non-enrolled Green party • The above information is true, I understand that voters to participate in certain 15 if it is not true, I can be convicted and fined up primary elections. Other to $5,000 and/or jailed for up to four years. I do not wish to enroll in a party Sign

I need to apply for Rev. 01/2011 Optional questions an Absentee ballot (optional). 14 I would like to be an Date Election Day worker (optional).

glue strip Address and stamp this section

Your address Place First-class stamp here

Your County Board of Elections address (select from below)

Before mailing Remove tape, fold and seal

New York City Chenango Franklin Lewis Oneida Putnam Schuyler Ulster Executive Offices 5 Court St. 355 West Main St. 7660 N. State St. Union Station 25 Old Route 6 County Office Bldg. 284 Wall St. 32 Broadway, 7th Fl. Norwich, NY 13815 Ste. 161 Lowville, NY 13367 321 Main St. Carmel, NY 10512 105 9th St., Unit 13 Kingston, NY 12401 New York, NY (607) 337-1760 Malone, NY 12953 (315) 376-5329 3rd Fl. (845) 808-1300 Watkins Glen, NY (845) 334-5470 10004 (518) 481-1663 Utica, NY 13501 14891 (212) 487-5300 Clinton Livingston (315) 798-5765 Rensselaer (607) 535-8195 Warren Cnty Government Ctr. Fulton County Govt. Ctr. Ned Pattison Cnty. Municipal Ctr. 137 Margaret St. 2714 St. Hwy 29 6 Court St. Onondaga Government Ctr. Seneca 1340 St. Rte. 9 Albany Ste. 104 Ste. 1 Room 104 100 Erie Blvd West 1600 Seventh Ave. One DiPronio Dr. Lake George, NY 32 North Russell Road Plattsburgh, NY 12901 Johnstown, NY 12095 Geneseo, NY 14454 Syracuse, NY 13204 Troy, NY 12180 Waterloo, NY 13165 12845 Albany, NY 12206 (518) 565-4740 (518) 736-5526 (585) 243-7090 (315) 435-3312 (518) 270-2990 (315) 539-1760 (518) 761-6456 (518) 487-5060 Columbia Genesee Madison Ontario Rockland Steuben Washington Allegany 401 State St. County Building #1 County Office Bldg. 74 Ontario St. 11 New Hempstead Rd. 3 E. Pulteney Sq. 383 Broadway 6 Schuyler St. Hudson, NY 12534 15 Main St. N. Court St. Canandaigua, NY New City, NY 10956 Bath, NY 14810 Fort Edward, NY Belmont, NY 14813 (518) 828-3115 PO Box 284 PO Box 666 14424 (845) 638-5172 (607) 664-2260 12828 (585) 268-9294 Batavia, NY 14021 Wampsville, NY 13163 (585) 396-4005 (518) 746-2180 Cortland (585) 344-2550 (315) 366-2231 St. Lawrence Suffolk Broome County Office Bldg. Orange 48 Court St. PO Box 700 Wayne Government Plaza 60 Central Ave. Greene Monroe 25 Court Lane Canton, NY 13617 Yaphank Ave. 157 Montezuma St. Ext. 44 Hawley St. Room 102 411 Main St. 39 Main St. W. PO Box 30 (315) 379-2202 Yaphank, NY 11980 PO Box 636 PO Box 1766 Cortland, NY 13045 Ste. 437 Rochester, NY 14614 Goshen, NY 10924 (631) 852-4500 Lyons, NY 14489 Binghamton, NY (607) 753-5032 Catskill, NY 12414 (585) 753-1550 (845) 291-2444 Saratoga (315) 946-7400 13902 (518) 719-3550 50 W. High St. Sullivan (607) 778-2172 Delaware Montgomery Orleans Ballston Spa, NY Gov’t. Ctr. Westchester 3 Gallant Ave. Hamilton Old Courthouse County Admin. Bldg. 12020 100 North St. 25 Quarropas St. Cattaraugus Delhi, NY 13753 Rte. 8 9 Park St. 14016 State Rte. 31 (518) 885-2249 PO Box 5012 White Plains, NY 302 Court St. (607) 746-2315 PO Box 175 PO Box 1500 Albion, NY 14411 Monticello, NY 12701 10601 Little Valley, NY 14755 Lake Pleasant, NY Fonda, NY 12068 (585) 589-3274 Schenectady (845) 807-0400 (914) 995-5700 (716) 938-2400 Dutchess 12108 (518) 853-8180 388 Broadway, Ste. E 47 Cannon St. (518) 548-4684 Oswego Schenectady, NY Tioga Wyoming Cayuga Poughkeepsie, NY Nassau 185 E. Seneca St. 12305 County Office Bldg. 4 Perry Ave. 10 Court St. 12601 Herkimer 240 Old Country Rd. Box 9 (518) 377-2469 56 Main St. Warsaw, NY 14569 Auburn, NY 13021 (845) 486-2473 109 Mary St. 5th Fl. Oswego, NY 13126 Owego, NY 13827 (585) 786-8931 (315) 253-1285 Ste. 1306 Mineola, NY 11501 (315) 349-8350 Schoharie (607) 687-8261 Erie County Office Bldg. Yates Chautauqua Herkimer, NY 13350 (516) 571-2411 134 W. Eagle St. (315) 867-1102 Otsego 284 Main St. Tompkins Ste. 1124 7 North Erie St. Buffalo, NY 14202 Niagara Ste. 2 PO Box 99 Court House Annex 417 Liberty St. Mayville, NY 14757 (716) 858-8891 Jefferson 111 Main St. 140 County Hwy. 33W Schoharie, NY 12157 128 E. Buffalo St. Penn Yan, NY 14527 (716) 753-4580 175 Arsenal St. Ste. 100 Cooperstown, NY (518) 295-8388 Ithaca, NY 14850 (315) 536-5135 Essex Chemung Watertown, NY 13601 Lock port, NY 14094 13326 (607) 274-5522 7551 Court St. (315) 785-3027 (716) 438-4040 (607) 547-4247 378 South Main St. PO Box 217 PO Box 588 Elizabethtown, NY Elmira, NY 14902 12932 (607) 737-5475 (518) 873-3474

(Optional) Register to donate your organs and tissues If you would like to be an organ and tissue donor, you may enroll in You will receive a confirmation letter from DOH, which will also the NYS Department of Health (DOH) Donate Life™ Registry online provide you an opportunity to limit your donation. at www.nyhealth.gov or provide your name and address below.

Last name By signing below, you certify that you are: First name • 18 years of age or older; Middle Initial Suffix • consenting to donate all of your organs and tissues for transplantation, research, or both; Address • authorizing the Board of Elections to provide your name and identifying information to DOH for enrollment in the Registry; Apt. Number Zip code • and authorizing DOH to allow access to this in- formation to federally regulated organ procure- City ment organizations and NYS-licensed tissue and eye banks and hospitals upon your death. Birth date M M / D D / Y Y Y Y Sex M F

Eye color Height Ft. In. Sign Date