CITY OF BROCKTON - SPECIAL INSTRUCTIONS: RETURN WITHIN TEN (10) DAYS
COMPLIANCE with this State requirement provides proof of residence, protection of voting rights, veteran's bonus, housing for the
elderly and related benefits
well as providing information for your community. This
DOES NOT register you as a voter,
political party. To register
change party, please obtain a mail-in registration
contact the Elections Commission. You
be a registered
State Primaries and Elections.
GENERAL INSTRUCTIONS: PLEASE PRINT
Please verify and/or complete all information listed on this form, then sign and date it. Make corrections as
RESIDENT ADDRESS - If your resident address
incorrect, make the change
the space to the right of the
PHONE NUMBER - Please print and/or verify your phone number
the indicated space.
"X" in the box next to the word "Unlisted".
DELETIONS - Put a line through the name of any resident no longer residing at this address and list his/her
new address. Make all changes on the SHADED line below the printed line.
A - LINE NUMBER
B - NAMES OF
FAMILY / HOUSEHOLD MEMBERS
THIS ADDRESS - Includes any member of the
Military Service, away at school or confined to a rest home. If a NEW member has been added to
the family or household, enter the name and information
the space provided on the form.
TO - This
the designated individual to whom this form has been sent. If you wish to change your
designated mail to contact, please place a "Y" next to the name of the selected individual. ONLY ONE "HEAD
OF HOUSEHOLD" may be designated
order to have the entire family listed together.
D - DATE OF BIRTH - "MM
=Day, YYYY =Year." If your date of birth is blank or incorrect,
please make appropriate changes.
E - OCCUPATION - Enter occupation, not place of employment.
F - MOVED/DECEASED - If this person has moved or is deceased, please indicate with
"M" or "D".
G - NATIONALITY -
you are NOT a U.S. Citizen, please indicate your nationality.
H - POLITICAL PARTY - "R" for REPUBLICAN, "D" FOR DEMOCRAT,
"J" for GREEN-RAINBOW PARTY
and "U" for UNENROLLED. All other letters represent political party designations. This reflects the
information on file and can only
updated by completing the necessary voter registration or party enrollment
I - PUBLIC SAFETY - Check this box if you are a member of a public safety agency and WORK AND LIVE
J - VOTER STATUS - Indicates whether a person is an active or inactive voter. Returning this form will
reactivate voter status unless the voter indicates that he / she has moved and signs the form.
K - NO. OF DOGS - Number of dogs licensed to this individual.
L - VETERAN - Write a "Y" if you are a veteran of the U.S. Armed Forces.
IF YOU HAVE
THE ELECTIONS COMMISSION
the provided return envelope and mail
Copyright 2007-2012 Mark Altman & Associa!es, Inc All Rights Reserved.
MAIL FORM TO: ELECTIONS COMMISSION
45 SCHOOL ST.
BROCKTON, MA 02301