PLEASE PRINT AND USE BLACK INK TO COMPLETE
ARKANSAS VOTER REGISTRATION APPLICATION
Rev. 6-13-17
Check all that apply:
____ This is a new registration.
____ This is a name change.
____ This is an address change.
____ This is a party change.
Ofce Use Only
Assigned ID
1
2
3
4
7
5
6
Mr.
Mrs.
Miss
Ms.
Last Name
Jr. Sr.
II. III. IV.
First Name Middle Name
Address Where You Live (See Section “C” Below)
(Rural addresses must draw map.)
Apt. or Lot#
City/Town County
ZIP Code
State
Address Where You Receive Mail If Different From Above
Apt. or Lot#
City/Town County
ZIP Code
State
Date of Birth _________/_________/_________
Month Day Year
Home & Work Phone Numbers (Optional)
(H) (W)
Party Afliation (Optional)
E-mail Address (Optional)
8
Have you ever voted in a federal election in this State? c Yes c No
Signature of elector - Please sign full name or put mark.
The information I have provided is true to the best of my knowledge. I do not claim the right
to vote in another county or state. If I have provided false information, I may be subject to
a ne of up to $10,000 and/or imprisonment of up to 10 years under state and federal laws.
9
10
11
Date: _____________/_____________/_____________
Month Day Year
If applicant is unable to sign his/her name, provide name, address and phone
number of the person providing assistance:
Name __________________________ Address: ________________________
City:_____________________ State:_____ Phone#:_____________________
ID Number - Check the applicable box and provide the appropriate number.
c
Arkansas Driver’s license number
_ ___________________________________
c If you do not have a driver’s license provide the last 4 digits of social
security number __________________________________________
c I have neither a driver’s license nor social security number.
(A) Are you a citizen of the United States of America and an Arkansas resident?
c Yes c No
(B) Will you be eighteen (18) years of age or older on or before election day?
c Yes c No
(C)
Are you presently adjudged mentally incompetent by a court of competent jurisdiction
?
c Yes c No
(D) Have you ever been convicted of a felony without your sentence having been
discharged or pardoned?
c Yes c No
If you checked No in response to either questions A or B, do not complete this form.
If you checked Yes in response to either questions C or D, do not complete this form.
Please complete the sections below if:
MAIL REGISTRANTS: PLEASE SEE SECTION D.
• You were previously registered in another county or state, or
• You wish to change the name or address on your current registration.
Agency Code (For Ofcial Use Only)
A
Mr.
Mrs.
Miss
Ms.
Previous Last Name
Jr. Sr.
II. III. IV.
First Name Middle Name
Date of Birth
_________/_________/_________
Month Day Year
B
Previous House Number and Street Name
Apt. or Lot#
City/Town County
ZIP Code
State
If you live in a rural area but do not have a house or street number,
or if you have no address, please show on the map where you live.
C
• Write in the names of the crossroads (or streets) nearest where you live.
• Draw an “X” to show where you live.
• Use a dot to show any schools, churches, stores or other landmarks near
where you live and write the name of the landmark.
D
IDENTIFICATION REQUIREMENTS
IMPORTANT:
Applicants will be required to
verify their registration when voting in person or by
absentee ballot by providing a required document
or identication card as provided in Arkansas
Constitution, Amendment 51, Section 13.
If your
voter registration application form is submitted by
mail and you are registering for the rst time, and
you do not have a valid Arkansas driver’s license
number or social security number, in order to avoid
the additional identication requirements upon
voting for the rst time you must submit with the
mailed registration form: (a) a current and valid
photo identication; or (b) a copy of a current utility
bill, bank statement, government check, paycheck,
or other government document that shows your
name and address.
Example
• Grocery
Store
• Public School
X
NORTH
Woodchuck Road
Route #2
PA 04
