Page 1 DSBE·02/2021 REGISTER AND Pennsylvania VOTE Voter Registration Application
Register to vote With this form, you can Send or deliver this form In the military? register to vote in elections To be registered in the next election, mail or If you are on active duty or you are a hospitalized in Pennsylvania. deliver your application form to your county or bedridden veteran, you can register at any voter registration office at least 15 days before time. See www.fvap.gov for more information. You can also use this form to: the next election. • Change the information on your Addresses for all Pennsylvania counties are College student in Pennsylvania voter registration. listed on page 2. Pennsylvania? • Register with a political party or change If your registration is accepted, you will receive the party you have selected. a Voter Registration Card from your county by If you are a college student who attends college nonforwardable mail. in Pennsylvania, you can register where you live If you are currently registered to vote in while attending school. Pennsylvania, you do not have to use this form Your registration is not complete until unless you have moved or changed your name. processed and accepted by your county voter For more information, see www.vote.pa.gov. registration office. You may only register and vote in one place. To register you must: If you do not receive your Voter Registration Card within 7-10 days, contact your county In prison or convicted of a • Be a United States citizen for at least 30 days voter registration office. before the next election. felony? • Be a resident of Pennsylvania and your election district for at least 30 days before Verifying your identity If you meet all other requirements, you may register and vote if: the next election. When you vote for the first time in your election • Be at least 18 years of age on the day of the district, you must show a form of identification. • You are in prison awaiting trial but have not next election. been convicted. For a complete list of acceptable forms of photo • You are in prison after being convicted of a and non-photo identification, visit misdemeanor only. www.vote.pa.gov/ID or call your County Board of Elections or 1-877-868-3772. • You have been released from prison or a halfway house after completing your term of Register online incarceration. • You are on probation or released on parole. You can also register to vote on t he web. • You are under house arrest. You should register at the address where you Go to vote.pa.gov/Register. live, except that you cannot use a prison or half-way house address for your registration. See www.vote.pa.gov for more information.
Questions?
Call your County Voter For more information about Informaci n en espa ol: Registration Office voting, visit our website: Si le interesa obtener este formulario en espa ol, llame al 1-877-868-3772. or call 1-877-868-3772. www.vote.pa.gov.
PENALTY FOR FALSIFYING DECLARATION Confidentiality Warning: If a person signs an official registration application knowing a statement If you decline to register to vote, the fact that declared in the application to be false. makes a false registration, or furnishes false you declined will remain confidential, and will information, the person commits perjury. be used for voter registration purposes only. Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven If you register to vote, the office at which you years. or a fine not exceeding $15,000, or both, at the discretion of the court. register will remain confidential and will be used for voter registration purposes only. Submitting an application containing false information may also subject a person to other penalties, including loss of the right of suffrage, under state or federal law. Page 2 Pennsylvania County Voter Registration Office addresses PA-DOS VRAD 01.2021
Adams Chester Fulton Mercer Susquehanna 117 Baltimore St 601 Westtown Rd 116 W Market St 5 Courthouse PO Box 218 Rm 106 Ste 150 Ste 205 Mercer PA 16137-1227 31 Lake Ave Gettysburg PA 17325 PO Box 2747 McConnellsburg PA 17233 (724) 662-7542 Montrose PA 18801 (717) 337-9832 West Chester PA 19380-0990 (717) 485-6872 (570) 278-6697 (610) 344-6410 Mifflin Allegheny Greene 20 N Wayne St Tioga 542 Forbes Ave Clarion 93 E High St Lewistown PA 17044 118 Main St Ste 609 Administrative Building Rm 102 (717) 248-6571 Wellsboro PA 16901 Pittsburgh PA 15219-2913 330 Main St Waynesburg PA 15370 (570) 723-8230 (412) 350-4500 Rm 104 (724) 852-5230 Monroe Clarion PA 16214 One Quaker Plaza Union Armstrong (814) 226-4000 Ext 2006 Huntingdon Rm 105 155 N 15th St Administration Bldg Bailey Building Stroudsburg PA 18360 Lewisburg PA 17837-8822 450 E Market St Clearfield 233 Penn St (570) 517-3165 (570) 524-8681 Ste 207 212 E Locust St Huntingdon PA 16652-1486 Kittanning PA 16201 Ste 106 (814) 643-3091 Ext 205 Montgomery Venango (724) 548-3222 Clearfield PA 16830 Voter Services 1174 Elk St (814) 765-2642 ext 5053 Indiana PO Box 311 PO Box 831 Beaver 825 Philadelphia St Norristown PA 19404-0311 Franklin PA 16323-0831 810 Third St Clinton Indiana PA 15701-3934 (610) 278-3280 (814) 432-9514 Beaver PA 15009 2 Piper Way (724) 465-3852 (724) 770-4440 Ste 309 Montour Warren Lock Haven PA 17745 Jefferson 253 Mill St 204 4th Ave Bedford (570) 893-4019 155 Main St Danville PA 17821 Warren PA 16365 200 S Juliana St Jefferson Place (570) 271-3002 (814) 728-3406 3rd Fl Columbia Brookville PA 15825-1269 Ste 301 PO Box 380 (814) 849-1693 Northampton Washington Bedford PA 15522 Bloomsburg PA 17815-0380 Elections Division 100 W Beau St (814) 623-4807 (570) 389-5640 Juniata 669 Washington St Rm 206 1 N Main St Easton PA 18042 Washington PA 15301 Berks Crawford PO Box 68 (610) 829-6260 (724) 228-6750 633 Court St 903 Diamond Park Mifflintown PA 17059 1st Fl Meadville PA 16335 (717) 436-7706 Northumberland Wayne Reading PA 19601 (814) 333-7307 320 N 2nd St 925 Court St (610) 478-6490 Lackawanna Ste 1 Honesdale PA 18431 Cumberland 123 Wyoming Ave Sunbury PA 17801 (570) 253-5978 Blair 1601 Ritner Highway 2nd Floor (570) 988-4208 279A Loop Road Ste 201 Scranton PA 18503 Westmoreland Hollidaysburg PA 16648 Carlisle PA 17013 (570) 963-6737 Perry 2 N Main St (814) 693-3287 (717) 240-6385 PO Box 37 Ste 109 Lancaster New Bloomfield PA 17068 Greensburg PA 15601 Bradford Dauphin PO Box 2139 (717) 582-2131 ext 4110 (724) 830-3150 6 Court St PO Box 1295 Lancaster PA 17608 Ste 2 Harrisburg PA 17108-1295 (717) 299-8293 Philadelphia Wyoming Towanda PA 18848 (717) 780-6360 520 N Columbus Blvd 1 Courthouse Sq
(570) 265-1717 Lawrence Philadelphia PA Tunkhannock PA 18657 Delaware 430 Court St 19123-4295 (570) 996-2226 Bucks Govt Center Bldg New Castle PA 16101 (215) 686-1590 55 E Court St 201 W Front St (724) 656-2161 York Doylestown PA 18901-4318 Media PA 19063-2728 Pike 28 E Market St (215) 348-6163 (610) 891-4659 Lebanon 506 Broad St York PA 17401-1579 400 S 8th St Milford PA 18337 (717) 771-9604 Butler Elk Municipal Bldg (570) 296-3427 PO Box 1208 300 Center St Rm 209 Butler PA 16003 PO Box 448 Lebanon PA 17042 Potter 1 N Main St (724) 284-5308 Ridgway PA 15853-0448 (717) 228-4428 For a listing of available email (814)776-5337 Ste 204 Cambria Lehigh Coudersport PA 16915 addresses, go to 200 S Center St Erie 17 S 7th St (814) 274-8467 www.vote.pa.gov/county. Ebensburg PA 15931 140 W 6th St Allentown PA 18101-2401 (814) 472-1464 Rm 112 (610) 782-3194 Schuylkill Erie PA 16501 420 N Centre St Cameron (814) 451-6276 Luzerne Pottsville PA 17901 20 E Fifth St 20 N Pennsylvania Ave (570) 628-1467 Emporium PA 15834-1469 Fayette Ste 207 (814) 486-9321 22 E Main St Wilkes-Barre PA 18701 Snyder Public Service Bldg (570) 825-1715 PO Box 217 Carbon Uniontown PA 15401 Middleburg PA 17842-0217 410 Center Ave (724) 430-1289 Lycoming (570) 837-4207 Jim Thorpe PA 18229-0170 48 W Third St (570) 325-4801 Forest Williamsport PA 17701-9536 Somerset 526 Elm St (570) 327-2267 300 N Center Ave Centre Box 3 Ste 340 420 Holmes St Tionesta PA 16353 McKean Somerset PA 15501 Willowbank Office Bldg (814) 755-3537 500 W Main St (814) 445-1549 Bellefonte PA 16823-1486 Smethport PA 16749 (814) 355-6703 Franklin (814) 887-3203 Sullivan 157 Lincoln Way East 245 Muncy St Chambersburg PA 17201-2211 PO Box 157 (717) 261-3886 Laporte PA 18626 (570) 946-5201 ext 7 Page 3 DSBE·02/2021 Pennsylvania Voter Registration Application Use black ink
Last name Jr Sr II III IV Print your name 1 First name Middle name or initial
Eligibility Are you a citizen of the U.S.? Yes No If you answer “No” to 2 Will you be 18 years or older either question, you cannot Yes No on or before election day? register to vote.
New registration Change of name Change of address Reason 3 Change of party Federal or State employee registering in county of last residence About you Birth date Sex M F Race (optional) Phone and email are optional 4 and used if information is Phone missing on this form. Email
Your address Address (not P.O. Box) Apt. number If you do not have a street City/Town State PA Zip Code address or a permanent 5 residence, or are a student, Municipality County see the instructions. I do not have a street address or permanent residence (use map on back)
The address where Same as above Address or P.O. Box 6 you receive mail City/Town State Zip Code
Identification PA driver's license or PennDOT ID card number If you have a Penn DOT number, you must use it. If not, please provide 7 Last four digits of your Social Security number X X X - X X - the last four digits of your Social Security number. I do not have a PA driver’s license or a PennDOT ID card or a Social Security number. See Verifying your identity. Political party Democratic Republican Green Libertarian None (No Affiliation) To vote in a primary, you 8 must register with either the Other Democratic or Republican party.
I require help to vote. I need this kind of assistance: Voting assistance 9 I require language help. My preferred language is:
Name on previous registration If your name Full previous address and county or address has PA Voter No. (if available) Year changed 10 Skip if this is the first time you Transfer Permanent Ballot Request are registering to vote. By checking the box, you are requesting that you continue to maintain your annual ballot request status when updating your address.
I declare that: Signature or mark • I am a United States citizen and will have been a citizen for at least 30 days on the day of the next election. • I will be at least 18 years old on the day of the next election. • I will have lived at the same address in Section 5 for at least 11 30 days before the election. Declaration • I am legally qualified to vote. I affirm that this information is true. I understand that this declaration is the same as an affidavit, and, if this information Print name is not true, I can be convicted of perjury, and fined up to $15,000, jailed for up to seven years, or both. Today's date
Help with this form Name of assistant Fill in if someone helped you 12 Address with this form or witnessed you make a mark for your signature. Phone Signature of assistant Page 4 Be a poll worker I would like to be a poll worker on Election Day. If you check either of these boxes, 13 I would like to be a bilingual interpreter on Election Day. I speak this language: your county voter registration office ______will contact you. Instructions for Section 5: Draw your map here. Example map. Do not use this map. How to show your address on a map If you live in a rural area and do not have a street address, • Gas use the map to the right to show where you live. • Library station with landmarks and road names. If you are homeless, use the map to the right to show where you Main St spend most of your time.
How to fill in the map: 40 Route • Write the names of the roads or streets nearest to where you live. • School • Draw an X to show where you live. X • Use a dot to show the location of landmarks, such as schools, churches, or stores, and identify them by name.
Fold here
Your address Place First-class stamp here
Your County Voter Registration Office address:
Fold here
Fold, tape shut, and mail to your Tape here County Voter Registration Office. Do not use staples. Tape here Tape County Voter Registration Office addresses are listed on page 2.
Tape here