Please print clearly in black ink.
This application can be used for:
• First time registration
• Request to vote by mail permanently
• Name change
• Address change
Last Name First Name M.I. Sufx (Jr., II)
HI Driver License or HI State ID Number
If you do not have either, complete box 3b.
Date of Birth Phone Number Email
Residence Address (P.O. Box, R.R., S.R. are not acceptable) Apt. Number City Zip Code
Apt. Number City Zip CodeMailing Address in Hawaii
Same as Residence Address
If your residence does not have a street address, describe the location (cross streets, landmarks).
Are you registered to vote in another state?
Last Registered Address, County, State, and Zip Code
Would you like to permanently receive absentee ballots by mail?
Yes. I hereby authorize cancellation of my previous registration.
Complete box 6b.
Yes. I request to permanently receive absentee ballots at the mailing address associated with my voter registration.
I understand that my permanent absentee voter status will be terminated if: 1) I request termination in writing; 2) I die, lose voting rights, register in another
jurisdiction, or am otherwise disqualied from voting; 3) my absentee ballot, voter notication postcard, or any other election mail is returned to the clerk as
undeliverable for any reason; or 4) I do not return my ballot by 6:00 PM on election day in both the primary and general election of an election year. If so, I understand
that I must reapply for permanent absentee status.
Warning: Any person who knowingly furnishes false information may be guilty of a Class C felony.
I hereby swear (or afrm) that all information furnished on this application is true and correct.
If you are unable to sign, mark the signature line and have a witness provide signature, address, and phone number.
I do not have a HI Driver License, HI State ID, or SSN.
I do not have a HI Driver License or HI State ID.
Provide the last 4-digits of your Social Security Number.
Notice: The identity of the voter registration agency through which any particular voter was registered shall not be publicly disclosed. A person’s declination to register to vote is
also condential and is used for voter registration purposes only (National Voter Registration Act of 1993).
ID Number Location Code Document Number
Are you a citizen of the United States of America?
Are you at least 16 years of age? (Must be 18 to vote)
Are you a resident of the State of Hawaii?
If you answered “No” to any of the above, DO NOT complete this form.
The residence stated in this afdavit is not simply
because of my presence in the State, but was acquired
with the intent to make Hawaii my legal residence with
all the accompanying obligations therein.
Hawaii Voter Registration &
Permanent Absentee Application