Fillable FLORIDA THIRD-PARTY VOTER REGISTRATION (Florida Division of Corporations)

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FLORIDA THIRD-PARTY VOTER REGISTRATION (Florida Division of Corporations)

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The FLORIDA THIRD-PARTY VOTER REGISTRATION (Florida Division of Corporations) form is 3 pages long and contains:

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FLORIDA THIRD-PARTY VOTER REGISTRATION
ORGANIZATION REGISTRATION FORM
Check applicable box: Original Registration Update to Registration Termination of Registration
1. Third Party Voter Registration Organization (name):
Phone:
Permanent Address:
___________________________________________________________________________
(address, city, county, state, zip code)
Email address, if any: ______________________________________________________________________
Mailing Address:
(if different from above)
___________________________________________________________________________
(street or PO Box address, city, county, state, zip code)
2. Designation of Organization’s Registered Agent in the State of Florida (name):
Phone:
Address:
(P.O. Box not permitted)
___________________________________________________________________________
(street address, city, county, state, zip code)
3. Registered Agent’s Acceptance: I accept the appointment as registered agent for this organization:
_______________________________________________________________________________ Date: ________________
(Signature of registered agent or authorized person signing for an organizational registered agent)
4. Indicate the counties in which the third-party voter registration organization will operate:
[ ] All counties;
[ ] Specific counties of: _____________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
5. Listing of the third-party voter registration organization’s officers:
Name
Title
Address
DS-DE 119 (eff. 09/2012) - page 1 Rule 1S-2.042, F.A.C.
FLORIDA THIRD-PARTY VOTER REGISTRATION ORGANIZATION
R
EGISTRATION FORM (CONTINUED)
6. Listing of the third-party voter registration organization’s employee registration agents (i.e., those
individuals employed by the organization who collect voter registration applications from Florida voter
registration applicants on behalf of the organization).
An address must include a street address, city, state, and zip code.
Check Applicable box: □ Initial Appointment □ Amended Entry □ Termination
Name of registration agent: _______________________________________________________________________
Permanent address: _____________________________________________________________________________
Temporary address, if applicable: _________________________________________________________________
Check Applicable box: □ Initial Appointment □ Amended Entry □ Termination
Name of registration agent: _______________________________________________________________________
Permanent address: _____________________________________________________________________________
Temporary address, if applicable: _________________________________________________________________
Check Applicable box: □ Initial Appointment □ Amended Entry □ Termination
Name of registration agent: _______________________________________________________________________
Permanent address: _____________________________________________________________________________
Temporary address, if applicable: _________________________________________________________________
7. Further Instructions. (a) If more entries are required to list additional organization’s officers, attach letter-
size paper and provide the same information as requested in Block 5 of this form.
(b) If more entries are required to list additional employee registration agents, use or copy the next page of this form
in a sufficient quantity to list all registration agents, then complete the pages and attach to this form.
(c) If you are updating a registration: Check the “Update to Registration” box, complete the name of the
organization in Block 1, but also place the organization’s 3P number in the name entry; and then only complete
those entries on the form that are being updated and Block 8.
(d) If you are terminating the organization’s registration: Check the “Termination of Registration” box,
complete the name of the organization in Block 1, but also place the organization’s 3P number in the name
entry; and then only complete Block 8.
(e) If you use continuation pages, state the number of additional pages here: _________ additional pages.
8. Signature: I understand that the above-named organization is not considered registered and may not collect any
voter registration application until the Division approves the registration and
assigns the organization an identification number.
_________________________________________ ___________________________ _______________
Name and Title of Person Completing Form Signature Date
DS-DE 119 (eff. 09/2012) – page 2 Rule 1S-2.042, F.A.C.
F
LORIDA THIRD-PARTY VOTER REGISTRATION ORGANIZATION
R
EGISTRATION FORM (CONTINUED) – ADDITIONAL PAGE # _____
6. (Continued) Listing of the third-party voter registration organization’s employee registration agents (i.e.,
those individuals employed by the organization who collect voter registration applications from Florida voter
registration applicants on behalf of the organization).
An address must include a street address, city, state, and zip code.
Complete the Additional Page # entry at the top of this form for each additional page.
Check Applicable box: □ Initial Appointment □ Amended Entry □ Termination
Name of registration agent: _______________________________________________________________________
Permanent address: _____________________________________________________________________________
Temporary address, if applicable: _________________________________________________________________
Check Applicable box: □ Initial Appointment □ Amended Entry □ Termination
Name of registration agent: _______________________________________________________________________
Permanent address: _____________________________________________________________________________
Temporary address, if applicable: _________________________________________________________________
Check Applicable box: □ Initial Appointment □ Amended Entry □ Termination
Name of registration agent: _______________________________________________________________________
Permanent address: _____________________________________________________________________________
Temporary address, if applicable: _________________________________________________________________
Check Applicable box: □ Initial Appointment □ Amended Entry □ Termination
Name of registration agent: _______________________________________________________________________
Permanent address: _____________________________________________________________________________
Temporary address, if applicable: _________________________________________________________________
Check Applicable box: □ Initial Appointment □ Amended Entry □ Termination
Name of registration agent: _______________________________________________________________________
Permanent address: _____________________________________________________________________________
Temporary address, if applicable: _________________________________________________________________
DS-DE 119 (eff. 09/2012) – additional page Rule 1S-2.042, F.A.C.
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FLORIDA THIRD-PARTY VOTER REGISTRATION (Florida Division of Corporations)

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Completed 30 July 2020

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