Texas Voter Registration Application
Prescribed by the Ofce of the Secretary of State VR17.09E.I3
For Ofcial Use Only
Please complete sections by printing LEGIBLY. If you have any questions about how to ll out this application,
please call your local voter registrar or the Secretary of State's Ofce toll free at 1-800-252-VOTE(8683), TDD
1-800-735-2989, www.sos.state.tx.us.
1 These Questions Must Be Completed Before Proceeding
Check one
New Application Change of Address, Name,
or Other Information
Request for a Replacement Card
Are you a United States Citizen? Yes No
Will you be 18 years of age on or before election day? Yes No
If you checked 'No' in response to either of the above, do not complete this form.
Are you interested in serving as an election worker? Yes No
2
Last Name Include Sufx if any
(Jr, Sr, III)
First Name Middle Name
(If any)
Former Name (if any)
3
Residence Address: Street Address and Apartment Number. If none,
describe where you live. (Do not include P.O. Box, Rural Rt. or Business Address)
City
TEXAS
Zip Code
4
Mailing Address: Street Address and Apartment Number. (If mail
cannot be delivered to your residence address.)
City
State
Zip Code
5
Date of Birth: (mm/dd/yyyy)
6
Gender (Optional)
Male
Female
7
Telephone Number (Optional)
Include Area Code
( )
8
Texas Driver's License No. or Texas Personal
I.D. No. (Issued by the Department of Public Safety)
If no Texas Driver's License or Personal Identication,
give last 4 digits of your Social Security Number
xxx-xx-
I have not been issued a Texas Driver's License/Personal Identication Number or
Social Security Number.
9
I understand that giving false information to procure a voter registration is perjury, and a crime under
state and federal law. Conviction of this crime may result in imprisonment up to 180 days, a ne up to
$2,000, or both. Please read all three statements to afrm before signing.
• I am a resident of this county and a U.S. citizen;
• I have not been nally convicted of a felony, or if a felon, I have completed all of my punishment
including any term of incarceration, parole, supervision, period of probation, or I have been
pardoned; and
• I have not been determined by a nal judgment of a court exercising probate jurisdiction to
be totally mentally incapacitated or partially mentally incapacitated without the right to vote.
X
Date / /
Signature of Applicant or Agent and Relationship to Applicant or Printed Name of Applicant if Signed by Witness and Date.
VR17.09EI3.indd 2 8/14/2009 10:12:25 AM
