Voter Registration Application Form General Instructions

Pennsylvania Voter Registration Application Form General Instructions

1. Please provide all information on the application as required. Read all instructions carefully before you fill out the application. 2. If you are currently registered, you do not need to re-register unless you have moved or changed your name since you last registered to vote. 3. In order to vote at the next election, this application must be received by your county voter registration office 30 days before the election, or postmarked no later than the thirtieth day before the election. Military electors may apply at any time. 4. Print out, fill in completely, sign and date the form. Place completed application in an envelope addressed to your local county voter registration office (addresses are available on the web at www.dos.state.pa.us) and affix the proper postage. 5. You are not registered to vote until your application has been processed and accepted by the county voter registration office. If accepted, the county voter registration office will send you, via nonforwardable mail, a Voter Identification Card. If you do not receive a Voter Identification Card within 14 days of the date you submit this application, contact your county voter registration office. 6. If you decline to register to vote, your decision will remain confidential. If you register to vote, the office at which you register will remain confidential. IDENTIFICATION WHEN YOU VOTE Pennsylvania law requires that registered voters who appear to vote for the first time in an election district after December 9, 2003 must present a form of identification. If this is the first election in which you are voting in your election district, and you intend to vote by absentee ballot in an election after January 1, 2004, you may include a form of identification with this voter registration application form rather than include it with your application for an absentee ballot. A list of the acceptable forms of identification may be obtained from your county voter registration office or from the Pennsylvania Department of State at its website, www.dos.state.pa.us INSTRUCTIONS FOR FILLING OUT THIS FORM (PLEASE READ CAREFULLY)

Box 1. Citizenship and Age: If the answer to either question is Box 5. Mailing Address: Fill in your mailing address, if “No,” do not complete this form because you are not eligible to different from Box 4a. register to vote. Box 6. Date of Birth: Fill in the month, day and year of Box 2. Application Type: Please check the appropriate box. If your birth. you are a Federal or State employee and wish to retain your voting Box 7. Race: Fill in your race (Optional). residence in the county where you last resided, please check the Box 8. Prior Registration: If you were registered before, appropriate box. fill in the name used on previous registration in Box 8a and Box 3. Name, Driver’s License and Social Security Number: address, county and year of previous registration in Box 8b. Print your last name, first name and middle name or initial. Circle Box 9. Political Party: Check block for political party or no Jr., Sr., II, III, IV if applicable. You must supply a Driver’s affiliation. You must register with a party if you want to take License Number if you have one. If you do not have a Driver’s part in that party’s primary. License Number, you must supply the last four digits of your Box 10. If you were assigned a Voter Identification Number, Social Security Number. If you do not have a Social Security which appears on your Voter Identification Card, place that Number, please write None in the boxes. Identification Number here. If you are applying to register to Box 4: 4a. Address of Residence: Fill in your complete address vote for the first time, leave this box blank. of residence. P.O. boxes may not be used here unless there is Box 11. Registration Declaration: You must be a citizen of no physical address. Print street address, city and zip code. (If the United States to register to vote in the Commonwealth of the residence is only a portion of the house, include the location or Pennsylvania. Please read the registration declaration number of the room, apartment or floor, which is occupied.) In carefully. Please sign and print your name and date the Box 4b include your telephone number (Optional). application. In Box 4c fill in the name of the municipality (city, borough or township) and county where you live. Use the map in the box PENALTY FOR FALSIFYING REGISTRATION below if you cannot otherwise identify your address. DECLARATION. WARNING: If a person signs an official registration application knowing a statement declared in the application to be false, makes a false registration, or furnishes false information, the person commits perjury. Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven years, or a fine not exceeding $15,000, or both, at the discretion of the court. 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

If your address of residence listed in Box 4a has no street number law. or street name (for example, Schoolhouse Road or RR2 Box 3) Box 12. Name of Assistant: If the applicant is unable to use the box above to draw a map of where you live. Include sign the application, the person who assisted the applicant landmarks and roads. must provide his or her name, address and telephone number. F

MOISTEN 3 SIDES FOLD SEAL AND MAIL Adhesive ADDRESSES OF COUNTY VOTER REGISTRATION OFFICES 7/16 in. Remoist To mail this application, write the address of the County Voter Registration Office in the proper area on the reverse side of this form. Full Horizontal ADAMS COUNTY CHESTER COUNTY FULTON COUNTY MERCER COUNTY SULLIVAN COUNTY 111-117 BALTIMORE ST 1ST FL 601 WESTTOWN RD PO BOX 2747 116 W MARKET ST STE 203 #5 COURTHOUSE PO BOX 157 GETTYSBURG PA 17325-2312 WEST CHESTER PA 19380-0990 MCCONNELLSBURG PA 17233 MERCER PA 16137-1227 LAPORTE PA 18626-0157 (717) 337-9832 (610) 344-6410 (717) 485-3691 (724) 662-3800 EXT 2240 (570) 946-5201 ALLEGHENY COUNTY CLARION COUNTY GREENE COUNTY MIFFLIN COUNTY SUSQUEHANNA COUNTY 542 FORBES AVE STE 604 421 MAIN ST 93 E HIGH ST RM 102 20 N WAYNE ST PO BOX 218 MAPLE ST PITTSBURGH PA 15219-2953 CLARION PA 16214-1093 WAYNESBURG PA 15370 LEWISTOWN PA 17044 MONTROSE PA 18801-0218 oist (412) 350-4500 (814) 226-4000 EXT 2205 (724) 852-5230 (717) 248-6571 (570) 278-4600 EXT 220 ARMSTRONG COUNTY CLEARFIELD COUNTY HUNTINGDON COUNTY MONROE COUNTY TIOGA COUNTY ADMIN/BLDG 500 E MARKET ST 230 E MARKET ST STE 108 223 PENN ST COURTHOUSE ONE QUAKER PLAZA RM 105 PO BOX 589 118 MAIN ST KITTANNING PA 16201 CLEARFIELD PA 16830 HUNTINGDON PA 16652-1486 STROUDSBURG PA 18360-2170 WELLSBORO PA 16901-0589 (724) 548-3222 (814) 765-2641 EXT 5996 (814) 643-3091 (570) 517-3165 (570) 723-8230 BEAVER COUNTY CLINTON COUNTY INDIANA COUNTY MONTGOMERY COUNTY UNION COUNTY 810 THIRD ST 232 E MAIN ST GARDEN BLDG 3RD FL 825 PHILADELPHIA ST COURTHOUSE PO BOX 311 103 S SECOND ST BEAVER PA 15009-2145 LOCK HAVEN PA 17745-1385 INDIANA PA 15701-3934 NORRISTOWN PA 19404-0311 LEWISBURG PA 17837-1996 (724) 728-3934 EXT 11298 (570) 893-4019 (724) 465-3852 (610) 278-3280 (570) 524-8681 BEDFORD COUNTY COLUMBIA COUNTY JEFFERSON COUNTY MONTOUR COUNTY VENANGO COUNTY

211 S JULIANA ST PO BOX 166 35 W MAIN ST PO BOX 380 155 MAIN ST JEFFERSON PLACE 29 MILL ST 1174 ELK ST PO BOX 831 MOISTEN BEDFORD PA 15522-0166 BLOOMSBURG PA 17815-0380 BROOKVILLE PA 15825-1269 DANVILLE PA 17821 FRANKLIN PA 16323-0831 (814) 623-4807 (570) 389-5640 (814) 849-1605 (570) 271-3000 (814) 432-9514 BERKS COUNTY CRAWFORD COUNTY JUNIATA COUNTY NORTHAMPTON COUNTY WARREN COUNTY 633 COURT ST 903 DIAMOND PARK BRIDGE ST PO BOX 68 WOLF BLDG 45 N SECOND ST 204 FOURTH AVE READING PA 19601-3540 MEADVILLE PA 16335-2678 MIFFLINTOWN PA 17059-0068 EASTON PA 18042-3695 WARREN PA 16365-2399 (610) 478-6490 (814) 333-7306 (717) 436-7706 (610) 559-3055 (814) 728-3401 BLAIR COUNTY CUMBERLAND COUNTY LACKAWANNA COUNTY NORTHUMBERLAND COUNTY WASHINGTON COUNTY 423 ALLEGHENY ST STE 043 37 E HIGH ST STE 104 135 JEFFERSON AVE SUITE 100 609 MARKET ST 100 W BEAU ST RM 206 HOLLIDAYSBURG PA 16648-2022 CARLISLE PA 17013-3044 SCRANTON PA 18503 SUNBURY PA 17801-2360 WASHINGTON PA 15301 MOISTEN (814) 693-3150 (717) 240-6385 (570) 963-6737 (570) 988-4208 (724) 228-6750 BRADFORD COUNTY DAUPHIN COUNTY LANCASTER COUNTY PERRY COUNTY WAYNE COUNTY 301 MAIN ST PO BOX 1295 PO BOX 83480 PO BOX 37 925 COURT ST TOWANDA PA 18848-1878 HARRISBURG PA 17108-1295 LANCASTER PA 17608-3480 NEW BLOOMFIELD PA 17068-0037 HONESDALE PA 18431-1996 (570) 265-1717 (717) 255-2793 (717) 299-8293 (717) 582-2131 EXT 4110 (570) 253-5978 BUCKS COUNTY DELAWARE COUNTY LAWRENCE COUNTY PHILADELPHIA COUNTY WESTMORELAND COUNTY 55 E COURT ST GOV'T CENTER BLDG 201 W FRONT ST 430 COURT ST 520 N DELAWARE AVE 5TH FL 2 N MAIN ST STE 109 DOYLESTOWN PA 18901-4318 MEDIA PA 19063-2728 NEW CASTLE PA 16101-3593 PHILADELPHIA PA 19123-4295 GREENSBURG PA 15601 (215) 348-6163 (610) 891-4659 (724) 656-2161 (215) 686-1505 (724) 830-3150 Adhesive BUTLER COUNTY ELK COUNTY LEBANON COUNTY PIKE COUNTY WYOMING COUNTY 3/8 in. Remoist PO BOX 1208 300 CENTER ST PO BOX 448 400 S EIGHTH ST 506 BROAD ST 1 COURTHOUSE SQ BUTLER PA 16003-1208 RIDGWAY PA 15853 LEBANON PA 17042-6794 MILFORD PA 18337-1535 TUNKHANNOCK PA 18657-1216 Partial (724) 284-5308 (814) 776-5337 (717) 274-2801 EXT 2243 (570) 296-3426 (570) 996-2226 CAMBRIA COUNTY ERIE COUNTY LEHIGH COUNTY POTTER COUNTY YORK COUNTY 200 S. CENTER ST 140 W 6TH ST RM 105 17 S 7TH ST 1 E SECOND ST RM 22A 1 WEST MARKETWAY EBENSBURG PA 15931 ERIE PA 16501-1096 ALLENTOWN PA 18101-2400 COUDERSPORT PA 16915-1690 YORK PA 17401-1256 (814) 472-5440 (814) 451-6275 (610) 782-3194 (814) 274-8467 (717) 771-9604 CAMERON COUNTY FAYETTE COUNTY LUZERNE COUNTY SCHUYLKILL COUNTY 20 E FIFTH ST 22 E MAIN ST PUBLIC SERVICE BLDG 200 N RIVER ST 114 S CLAUDE A LORD BLVD EMPORIUM PA 15834-1469 WILKES-BARRE PA 18711 POTTSVILLE PA 17901-3602 FOLD UNIONTOWN PA 15401 FOLD (814) 486-2315 (724) 430-1289 (570) 825-1715 (570) 622-3040 CARBON COUNTY FOREST COUNTY LYCOMING COUNTY SNYDER COUNTY For a listing of available BROADWAY & HAZARD SQ PO BOX 129 PO BOX 126 48 W THIRD ST PO BOX 217 JIM THORPE PA 18229-0129 TIONESTA PA 16353-0126 WILLIAMSPORT PA 17701-0536 MIDDLEBURG PA 17842-0217 county e-mail addresses, go to: Fold perf (570) 325-4801 (570) 327-2267 (570) 837-4209 (814) 755-3537 www.dos.state.pa.us full horiz. CENTRE COUNTY FRANKLIN COUNTY MCKEAN COUNTY SOMERSET COUNTY 420 HOLMES ST 157 LINCOLN WAY EAST PO BOX 1507 300 N CENTER AVE STE 510 If you are interested in becom- BELLEFONTE PA 16823-1488 CHAMBERSBURG PA 17201-2211 SMETHPORT PA 16749-0507 SOMERSET PA 15501 (814) 355-6703 (717) 261-3886 (814) 887-3203 (814) 445-1549 ing a poll worker, contact your county voter registration office. INSTRUCTIONS FOR FILLING OUT THIS FORM (PLEASE READ CAREFULLY) Box 1. Citizenship and Age: If the answer to either question is "No," do not Box 5. Mailing Address: Fill in mailing address, if different from Box 4a. complete this form because you are not eligible to register to vote. Box 2. Application Type: Please check the appropriate box. If you are a Federal Box 6. Date of Birth: Fill in month, day and year of your birth. or State employee and wish to retain your voting residence in the county Box 7. Race: Fill in your race. (Optional) where you last resided, please check the appropriate box. Box 8. Prior Registration: If you were registered before, fill in name of previous

Box 3. Name, Driver's License and Social Security Number: Print last name, registration in Box 8a and address, county and year of previous registra- MOISTEN first name and middle name or initial. Circle Jr., Sr., II, III, IV if application in Box 8b. ble. You must supply a Driver's License Number, if you have one. If you do not have a Driver's License Number, you must supply the last four dig- Box 9. Political Party: Check block for political party or no affiliation. You must its of your Social Security Number. If you do not have a Social Security register with a party if you want to take part in that party's primary. Number, please write None in the boxes. Box 10. If you were assigned a Voter Identification Number, which appears on Box 4. 4a Address of Residence: Fill in your complete address of residence. your Voter Identification Card, place that Identification Number here. If

MOISTEN P.O. boxes may not be used here unless there is no physical address. you are applying to register to vote for the first time leave this box blank. Print street address, city and zip code. (If the residence is only a portion of the house, include the location or number of the room, apartment or floor which is occupied.) In Box 4b include your telephone number. (Optional) Box 11. Registration Declaration: 11a You must be a citizen of the United States to register to vote in the Commonwealth of Pennsylvania.11b Please read In Box 4c fill in the name of the municipality (city, borough or township) and county where you live. Use the map in the box below if you can- the registration declaration carefully. Please sign and print your name and not otherwise identify your address. date the application.

NORTH PENALTY FOR FALSIFYING REGISTRATION DECLARATION Perforation WARNING: If a person signs an official registration application knowing a Rule Weight=1.1 pt statement declared in the application to be false, makes a false registration, or Reverse furnishes false information, the person commits perjury. Perjury is punishable, Full WEST EAST upon conviction, by a term of imprisonment not exceeding seven years, or a fine Rule,Horizontal Weight=0.5 pt not exceeding $15,000, or both, at the discretion of the court. Submitting an application containing false information may also subject a person to other Screen=10%, 150 line SOUTH penalties, including loss of the right of suffrage, under state or federal law. End esive If your address of residence listed in Box 4a has no street number or street Box 12. Name of Assistant: If the applicant is unable to sign the application, the name (for example, Schoolhouse Road or RR2 Box 3) use the box above person who assisted the applicant must provide his or her name, address adhesive FOLD to draw a map of where you live. Include landmarks and roads. and telephone number. FOLD here PENNSYLVANIA VOTER REGISTRATION APPLICATION Perforation DO NOT WRITE IN SHADED AREAS Rule Weight=0.5 pt 1 Are you a citizen of the United States of America? Yes No If you checked "No" in response to either of these Fill screen=100% Will you be 18 years of age on or before election day? Yes No } questions, do not complete this form. Full I am a Federal or State employee and wish to retain Fold/Perf. New Registration Change of Name Change of Address Change of Party Place either Driver's License # or Social Security # here 2 my voting residence in the county where I last resided. Horizontal Mr Last Name First Name Middle Name/Initial Jr Sr II DL # Mrs 3 Miss III IV OR SS# (last 4 digits) Perforation 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) Full Horizontal a PA b ( ) 4 Municipality where you live County where you live 5 Mailing address (if different than address of residence) City State Zip Code c REMOVE DO NOT SEAL HERE 6 Date of Birth78 Race (Optional) Name on previous registration 9 In which party do you wish to register? a Democratic No affiliation Address of previous registration County of previous registration Year of previous registration Republican Other (Please specify): 8 Libertarian b Green Voter Identification Place signature with full name (or mark) below. 10 Number (Please see Penalty for Falsifying Declaration.) 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

SEAL HERE DO NOT REMOVE 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 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 Print Your Name Below Date materially false statement, I will be subject to penalties for perjury. Name of person who assisted in the completion of this application Telephone No. DATE OF REGISTRATION REGISTRAR YEAR PARTY AFFILIATION 12 ONLY USE OFFICIAL Address

NAME CITY, BORO, OR TWP. WARD DISTRICT COUNTY VOTER I.D.# OFFICIAL ONLY USE

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