INFORMATION REQUIRED FROM ALL APPLICANTS
YES NO
1.
Are you presenting a voter registration card today?
2.
If not, are you registering to vote?
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 fine up to $2,000, or both. PLEASE READ ALL THREE STATEMENTS TO AFFIRM BEFORE SIGNING.
I am a resident of the county provided above, and a U.S. citizen; I have not been finally 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
final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially mentally incapacitated without the right to vote.
By providing my electronic signature, I understand the personal information on my application form and my electronic signature will be used for submitting my
voter’s registration application to the Texas Secretary of State’s office. Wanting to register to vote, I authorize the Department of Public Safety to transfer this
information to the Texas Secretary of State.
3.
Do you have a Texas driver license or learner license (unexpired, or expired for no more than 4 years)?
4.
Do you have a Texas identification card (unexpired, or expired for no more than 4 years)?
5.
Do you have a Texas license to carry / concealed handgun license (unexpired, or expired for no more than 4 years)?
6.
Do you have a U.S. passport book or card (unexpired, or expired for no more than 4 years)?
7.
Do you have a U.S. citizenship certificate that contains your photograph?
8.
Do you have a U.S. military identification card that contains your photograph (unexpired, or expired for no more than
4 years
)?
If answering “yes” to questions 3 through 8, you are not eligible to receive a Texas Election Identification Certificate.
CERTIFICATION
I do solemnly swear, affirm, or certify that I am the person named herein and that the statements on this application are true and correct.
X Date:
APPLICANT INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE NAME:
SUFFIX:
BIRTH SURNAME:
DATE OF BIRTH (mm/dd/yyyy): __________________________________
SSN: _____________________ SEX: (Select One) ____ MALE ____ FEMALE
EYE COLOR: HAIR COLOR:
RACE (Select One): ____ (A
I
) Alaskan or American Indian
____ (AP) Asian or Pacific Islander ____ (BK) Black ____ (W) White
ETHNICITY (Select One): ____ (H) Hispanic Origin
____ (O) Not of Hispanic Origin ____ (U) Unknown
HEIGHT: ft. in. WEIGHT: lbs.
UNITED STATES CITIZEN: YES NO
If you are not a U.S. citizen, you are not eligible for an Election Identification Certificate.
PLACE OF BIRTH: CITY: COUNTY: STATE: COUNTRY:
FATHER’S LAST NAME: MOTHER’S MAIDEN NAME:
CONTACT INFORMATION
HOME PHONE:
OTHER PHONE:
EMAIL:
ADDRESS INFORMATION
RESIDENCE ADDRESS:
CITY: STATE:
ZIP CODE: COUNTY:
MAILING ADDRESS:
CITY: STATE:
ZIP CODE: COUNTY:
FOR DEPARTMENT USE
ONLY
ASSIGNED #
APPLICATION FOR TEXAS ELECTION IDENTIFICATION CERTIFICATE
FOR ELECTION PURPOSES ONLY; CANNOT BE USED AS AN IDENTIFICATION CARD
NOTICE: All information on this application must be completed in INK.
APPLICATION FOR: (Please select one)
Original
Reissue (Renewal)
DL-14C (Rev. 2/2020)
VERIFICATION
Sworn to and subscribed before me this day of ,
Notary Public in and for the State of Texas or Authorized Officer
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