3b Pennyslvania Driver’s License OR Social Security Number: You Prior Registration: If you were registered before, fill in the name used must supply a PA Driver’s License Number if you have one. If you do on your previous registration in Box 8a and address, county and year of not have a PA Driver’s License Number, you must supply the last four previous registration in Box 8b. digits of your Social Security Number. If you do not have a Social Security Number, please check the box to the right of 3b. Name of Assistant: If the applicant is unable to complete or sign the application, the person who assisted the applicant must provide his or her 4a Address of Residence: Fill in your complete address of residence. name, address and signature. P.O. boxes may not be used here unless there is no physical address. Print street address, city and zip code. (If the residence is only a portion Registration Declaration: You must be a citizen of the United States to of the house, include the location of the room, apartment or register to vote in the Commonwealth of Pennsylvania. Please read the floor which is occupied.) 4b Although providing your telephone registration declaration carefully. You must sign and print your name and number is optional, it is a quick and easy way for your county to date the application. contact you if there is missing information on your registration form. If you were assigned at Voter Identification Number, which appears on In Box 4c fill in the name of the municipality (city, borough or your Voter Identification Card, place that Identification Number, if township) and county where you live. Use the map in the box below if available here. If you are applying to register to vote for the first time, you cannot otherwise identify your address. leave this box blank.

If you require assistance when voting, you must check the box and provide the reason. PENNSYLVANIA VOTER REGISTRATION APPLICATION 1 Are you a citizen of the United States of America? Yes No If you checked “No” in response to either of Will you be 18 years of age on or before election day? Yes No } these questions, do not complete this form. I am a Federal or State employee and wish to retain my voting New Registration Change of Name Change of Address Change of Party 2 residence in the county where I last resided. 3 M Last Name First Name Middle Name/Initial Jr Sr II III IV a F (circle if applicable) Place PA Driver’s If no PA DL #, Place I DO NOT have a PA Driver’s License 3 License (DL) # here SS# (last 4 digits) here: or Social Security Number. b if you have one: 4 Address of residence, include street and city (Use map above if no street number or name) (If only P.O. box, see above) Apt # State Zip Code 4 Telephone Number (Optional) a PA b ( ) 4 Municipality where you live County where you live Mailing Address (if different than address of residence) City State Zip Code c 5 6 Date of Birth 7 Race (Optional) 8 Name on previous registration Address of previous registration (include street and city) / / a 8 In which party do you wish to register? You must register with a party if you want to take part in that party’s primary. b County of previous registration Year of previous registration 9 Democratic Republican Libertarian No affiliation Other Name and signature of person who assisted in the completion of this application Place signatue with full name (or mark) below 10 (Please see Penalty for Falsifying Declaration.) Address

I HEREBY DECLARE THAT: 11 (1) On the day of the next election I will have been a United States citizen for at least one month. I will be at least 18 years of age, and I will have resided in Pennsylvania and in my election district for at least 30 days; X (2) I am legally qualified to vote. AND I HEREBY AFFIRM THAT the information I have provided in this Print Your Name Below Date: registration declaration is true. I understand that this registration declaration will be accepted for all purposes as the equivalent of an affidavit; and if the registration contains a materially false statement, I will be subject to penalties for perjury. / / Voter Identification Number 12 (If available - not necessary if you are registering to vote for the first time or if you do not know your number.) Do you require assistance Reason for assistance: 13 when voting? Yes No ADDRESSES OF COUNTY VOTER REGISTRATION OFFICES To mail this application, write the address of the County Voter Registration Office in the proper area on the reverse side of this form. ADAMS COUNTY BUCKS COUNTY COLUMBIA COUNTY GREENE COUNTY LEBANON COUNTY NORTHUMBERLAND COUNTY UNION COUNTY 111-117 BALTIMORE ST 55 E COURT ST 35 W MAIN ST PO BOX 380 93 E HIGH ST RM 102 400 S 8TH ST 609 MARKET ST 155 N 15TH ST GETTYSBURG PA 17325-2312 DOYLESTOWN PA 18901-4318 BLOOMSBURG PA 17815-0380 WAYNESBURG PA 15370 LEBANON PA 17042-6794 SUNBURY PA 17801-2360 LEWISBURG PA 17837-8822 (717) 337-9832 (215) 348-6163 (570) 389-5640 (724) 852-5230 (717) 274-2801 EXT 4428 (570) 988-4208 (570) 524-8681 ALLEGHENY COUNTY CRAWFORD COUNTY HUNTINGDON COUNTY LEHIGH COUNTY PERRY COUNTY VENANGO COUNTY BUTLER COUNTY 903 DIAMOND PARK 223 PENN ST COURTHOUSE 17 S 7TH ST PO BOX 37 1174 ELK ST PO BOX 831 542 FORBES ST STE 609 PO BOX 1208 P IT T S B U R G H PA 15219-2913 MEADVILLE PA 16335-2678 HUNTINGDON PA 16652-1486 ALLENTOWN PA 18101-2401 NEW BLOOMFIELD PA 17068-0037 FRANKLIN PA 16323-0831 BUTLER PA 16003-1208 (814) 333-7306 (814) 643-3091 (610) 782-3194 (717) 582-2131 EXT 4110 (814) 432-9514 (412) 350-4500 (724) 284-5308 ARMSTRONG COUNTY CUMBERLAND COUNTY INDIANA COUNTY MERCER COUNTY PHILADELPHIA COUNTY WARREN COUNTY 5 COURTHOUSE 450 E. MARKET ST, STE 207 CAMBRIA COUNTY 310 ALLEN RD 825 PHILADELPHIA ST 520 N DELAWARE AVE 5TH FL 204 4TH AVE KITTANNING PA 16201 CARLISLE PA 17013-3044 INDIANA PA 15701-3934 MERCER PA 16137-1227 PHILADELPHIA PA 19123-4295 WARREN PA 16365-2399 200 S CENTER ST (724) 662-3800 EXT 2240 (724) 548-3222 EBENSBURG PA 15931 (717) 240-6385 (724) 465-3852 (215) 686-1591 (814) 728-3406 BEAVER COUNTY (814) 472-1464 DAUPHIN COUNTY JEFFERSON COUNTY MIFFLIN COUNTY PIKE COUNTY WASHINGTON COUNTY 810 THIRD ST PO BOX 1295 155 MAIN ST JEFFERSON PLACE 20 N WAYNE ST 506 BROAD ST 100 W BEAU ST RM 206 BEAVER PA 15009 CHESTER COUNTY HARRISBURG PA 17108-1295 BROOKVILLE PA 15825-1269 LEWISTOWN PA 17044 MILFORD PA 18337-1535 WASHINGTON PA 15301 (724) 728-5700 601 WESTTOWN RD STE 150 (717) 780-6360 (814) 849-1605 (717) 248-6571 (570) 296-3426 (724) 228-6750 PO BOX 2747 BEDFORD COUNTY WEST CHESTER PA 19380-0990 DELAWARE COUNTY JUNIATA COUNTY MONROE COUNTY POTTER COUNTY WAYNE COUNTY ONE QUAKER PLAZA RM 105 200 SOUTH JULIANA ST 3RD FLOOR (610) 344-6410 GOVT CENTER BLDG 201 W FRONT ST BRIDGE ST PO BOX 68 1 NORTH MAIN ST 925 COURT ST BEDFORD PA 15522 MEDIA PA 19063-2728 MIFFLINTOWN PA 17059 STROUDSBURG PA 18360-2170 COUDERSPORT PA 16915 HONESDALE PA 18431-1996 (570) 517-3165 (814) 623-4807 CLARION COUNTY (610) 891-4659 (717) 436-7706 (814) 274-8467 (570) 253-5978 421 MAIN ST STE 19 ELK COUNTY LACKAWANNA COUNTY MONTGOMERY COUNTY SULLIVAN COUNTY WESTMORELAND COUNTY BERKS COUNTY CLARION PA 16214-1093 300 CENTER ST PO BOX 448 135 JEFFERSON AVE STE 100 COURTHOUSE PO BOX 311 PO BOX 157 2 N MAIN ST STE 109 633 COURT ST (814) 226-4000 EXT 2205 READING PA 19601 RIDGWAY PA 15853-0448 SCRANTON PA 18503 NORRISTOWN PA 19404-0311 LAPORTE PA 18626-0157 GREENSBURG PA 15601 (610) 478-6490 (814) 776-5337 (570) 963-6737 (610) 278-3280 (570) 946-5201 (724) 830-3150 CLEARFIELD COUNTY BLAIR COUNTY 230 E MARKET ST STE 108 ERIE COUNTY LANCASTER COUNTY MONTOUR COUNTY SUSQUEHANNA COUNTY WYOMING COUNTY 423 ALLEGHENY ST STE 043 CLEARFIELD PA 16830 140 W 6TH ST RM 105 150 NORTH QUEEN ST STE 102 29 MILL ST PO BOX 218 MAPLE ST 1 COURTHOUSE SQ HOLLIDAYSBURG PA 16648-2022 (814) 765-2641 EXT 5996 ERIE PA 16501-1096 LANCASTER PA 17603-3562 DANVILLE PA 17821 MONTROSE PA 18801-0218 TUNKHANNOCK PA 18657-1216 (814) 693-3150 (814) 451-6276 (717) 299-8293 (570) 271-3000 (570) 278-4600 EXT 220 (570) 996-2226 CLINTON COUNTY BRADFORD COUNTY FULTON COUNTY LAWRENCE COUNTY NORTHAMPTON COUNTY TIOGA COUNTY YORK COUNTY 232 E MAIN ST GARDEN BLDG 3RD FL 301 MAIN ST 116 W MARKET ST STE 203 430 COURT ST 670 WOLF AVE 118 MAIN ST 28 EAST MARKET ST LOCK HAVEN PA 17745-1385 TOWANDA PA 18848-1878 MCCONNELLSBURG PA 17233 NEW CASTLE PA 16101-3593 E AS TO N PA 18042-4343 WELLSBORO PA 16901-0589 YORK PA 17401-1579 (570) 893-4019 (570) 265-1717 (717) 485-3691 (724) 656-2161 (610) 559-3055 (570) 723-8230 (717) 771-9604