PLEASE COMPLETE THE APPLICATION BELOW. PLEASE PRINT USING A BLACK BALLPOINT PEN.
Florida Voter registration application
reQUired
reQUired
1
Check boxes that apply: New Registration Address Change Party Change Name Change Card Replacement Signature Update
2
Are you a citizen of the United States of America? Yes No
(If NO, you cannot register to vote)
3
I affirm I am not a convicted felon, or if I am, my rights relating to voting have been restored.
4
I affirm I have not been adjudicated mentally incapacitated with respect to voting or, if I have, my right to vote has been restored.
5
Date of Birth
(MM/DD/YYYY)
/ /
6
7
Last Name Suffix (circle)
Jr. Sr. II III IV
First Name
Middle Name/Initial
8
Address Where You Live (Legal Residence)
DO NOT GIVE P.O. BOX.
Apt/Lot/Unit City County of Legal Residence State Zip Code
9
Mailing Address If Different from Above Apt/Lot/Unit City Country State Zip Code
10
Address Last Registered to Vote Apt/Lot/Unit City County State Zip Code
11
Former Name if Making Name Change
Day Phone Number (optional)
12
Party Affiliation (Check only one) Democratic Party Republican Party minor party (print registered party name): NONE
13
Race/Ethnicity (Check only one) American Indian/Alaskan Native Asian/Pacific Islander Black, not Hispanic Hispanic White, not Hispanic
14
Sex M F Do you need voting assistance at the polls? Yes No Are you interested in being a poll worker? Yes No
State or Country of Birth
15
Are You:
Active Duty Military/Merchant Marine Dependent of Active Duty Military/Merchant Marine U.S. Citizen Currently Residing Outside the U.S.
16
OATH:
I do solemnly swear (or affirm) that I will protect and defend the
Constitution of the United States and the Constitution of the State of Florida, that
I am qualified to register as an elector under the Constitution and laws of the
State of Florida, and that all information provided in this application is true.
IF YOU ANSWERED NO TO QUESTION 2, OR IF YOU ARE UNABLE TO AFFIRM THE STATEMENTS IN BOXES 3 AND 4,
YOU ARE INELIGIBLE TO REGISTER TO VOTE. DO NOT COMPLETE THIS APPLICATION.
1) Black boxes must be completed on the application below for registration to be valid. 2) Return this completed application to the office of your supervisor of elections.
3) If you are a first-time voter in this state applying by mail to register to vote and you have not been issued a FL DL#, FL ID#, or SSN, include a copy of your ID with the application (see
Special Identification Requirements for additional information required). 4) Mail with first-class stamp.
SIGNATURE: Sign or mark on line in box below. (Invalid without signature or mark of applicant)
X
Date:
REVISED 1/08
If you have a current and valid FL DL# or FL ID card#, you must provide the number in this box. If you do not have
either, provide the last 4 digits of your SSN. If you have not been issued a FL DL#, FL ID card#, or SSN, write “NONE”:
You can use this form to:
• Register to vote in the State of Florida
• Change name or address
• Replace your defaced, lost or stolen Voter
Information Card
• Register with a political party or change
party afliation
• Update your signature
DeaDline information
If this is a new registration application in Florida,
the date the completed application is postmarked
or hand delivered to a driver’s license ofce,
a voter registration agency, an armed forces
recruitment ofce, the Division of Elections, or
the ofce of any supervisor of elections in the
state will be your registration date. You must be
registered for at least 29 days before you can vote
in an election. If your application is complete and
you are qualied as a voter, a voter information
card will be mailed to you.
PartY affiliation (Box #12)
If you wish to register with a major political
party, place an “X” in the box next to the desired
major party. If you wish to register with a minor
political party, place an “X” in the box preceding
“minor party” and then print the name of the
desired minor party. For a list of all political
parties registered in Florida, go to the Division
of Elections’ web site: http://election.dos.state.
fl.us/online/parties.shtml. If you do not wish to
register with any political party, place an “X” in
the box preceding “NONE.” Florida is a closed
primary election state. Therefore, to vote in a
primary election for partisan candidates, you
must be a registered voter in the party for which
a primary is being held. Regardless of party
afliation, all registered voters can vote on issues
and non-partisan candidates.
notice
The ofce at which you register or your decision
not to register, your SSN, your FL DL# and your
FL ID card# will remain condential and will be
used only for voter registration purposes.
note
If the information on this application is not true,
the applicant can be convicted of a felony of
the third degree and ned up to $5,000 and/or
imprisoned for up to ve years.
Questions
Contact the ofce of your county supervisor of
elections for additional information. Contact
information is on the website for the Division of
Elections: http://election.dos.state.fl.us/county/
index.shtml
información en esPañol
Sirvase llamar a la ocina del supervisor de
elecciones de su condado si le interesa obtener
este formulario en Español.
TO REGISTER, YOU MUST:
• Be a citizen of the United States of America. (Box 2)
• Be a Florida resident. (Box 8)
• Be 18 years old. (You may pre-register if you are 17 or
if you have a valid driver’s license before your 17th
birthday.) (Box 5)
• Not be adjudicated mentally incapacitated with respect
to voting unless that right is restored. (Box 4)
• Not be a convicted felon unless you have had your civil
rights restored. (Box 3)
• Provide your current and valid Florida driver’s license
number or Florida identification card number. If you
do not have a current and valid Florida driver’s license
or Florida identification card, you must provide the
last four digits of your Social Security number. If you
do not have a Florida driver’s license number, Florida
identification card number or Social Security number,
write “NONE” in the box. (Box 6)
• Complete all information in the black boxes on the ap-
plication. (Boxes 2, 3, 4, 5, 6, 7, 8, 16)
Florida Voter
Registration
Application
OFFICIAL USE ONLY:
DS DE 39 1/08
