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Voter Registration Application Form General Instructions

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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.
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