Fillable Form 1.: STATE OF ALASKA VOTER REGISTRATION APPLICATION (City of Homer)

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Form 1.: STATE OF ALASKA VOTER REGISTRATION APPLICATION (City of Homer)

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BROWSE CITY OF HOMER (AK) FORMS

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C03 (Rev. 01/29/2020)
STATE OF ALASKA VOTER REGISTRATION APPLICATION
Refer to instructions on the reverse side for specific information and identification requirements.
Please print clearly in blue or black ink.
1.
You MUST complete this section for registration:
Yes
Yes
No
No
I am a citizen of the United States.
I am at least 18 years old or will be within 90 days of completing this application.
If you checked NO to either question, do not complete this form as you are not eligible to register to
vote.
2. Last Name First Name Middle Initial Suffix
3. Former Name: (If your name has changed)
4.
You MUST provide the Alaska residence address where you claim residency. Do not use PO, PSC, HC or RR.
Alaska
House No.
Street Name
Apt No.
City
State
*
Keep my residence address confidential.
(Your mailing address in section 5 must be DIFFERENT from your
residence address in section 4 to remain confidential.)
5.
Mailing Address:
(Address where you receive your
mail if different from above)
7.
I am a voter with a disability and would like
information on alternative voting methods.
8.
I am interested in serving as an election official.
(Provide your phone number and/or email address in section 9.)
9.
Daytime Phone No.:
Evening Phone No.:
6.
*AK Voter Number:
Email Address:
(If known)
10.
Identifiers –
You
MUST
provide at least one:
*SSN or Last 4 of SSN:
/
/
*Alaska Driver’s License
or State ID Number
I have not been issued a Social Security Number, Alaska Driver’s License or State ID number.
11.
You MUST provide:
12.
Gender
Male Female
*Date of Birth
/
Month
Day
Year
13.
Political Affiliation For political affiliation choices in Alaska, see instruction number 4 on the reverse side.
Write political affiliation:
14
I am registered to vote in another state, cancel my registration in:
City:
State:
County:
Zip:
Voter Certificate. Read and Sign: I certify, under penalty of perjury, that the above information I provided on
this document is true and correct. I am not registered to vote in another state, or I have provided information to
cancel that registration. I further certify that I am a resident of Alaska and I have not been convicted of a felony, or
having been so convicted, have been unconditionally discharged from incarceration, probation and/or parole.
WARNING: If you provide false information on this application you can be convicted of a misdemeanor AS 15.56.050.
*SIGNATURE:
DATE:
Your signature must be a handwritten signature. A typed or digital signature is not valid.
Registrar/Agency/Official – Check ID and complete this section
OR
Registrar Name Voter No or SSN Agency Name
*Items are kept confidential by the Division of Elections and are not available for public inspection except that confidential addresses may
be released to government agencies or during election processes as set out in state law.
click to sign
signature
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State of Alaska - Division of Elections
Voter Registration Application
To register to vote in Alaska you must be a U.S. Citizen, a resident of Alaska, and at least 18 years old or
will be 18 years old within 90 days of completing this application.
Initial registration or registration changes must be made at least 30 days prior to an election. Once your application is
processed, a notice will be mailed to you within 3 to 4 weeks.
1. When Completing This Application You MUST Provide:
•
Alaska Residence Address Where You Claim Residency – A complete physical residence address in Alaska
must be included on your application. The residence address you provide will be used to assign your voter record
to a voting district and precinct. Your application will be denied if you do not provide an Alaska residence address
or you provide a PO Box, HC No. and Box, PSC Box, Rural Route No., Commercial Address or Mail Stop Address or
a residence address outside of Alaska on Line 4 of the application.
If your residence has been assigned a street name and house number, provide this information or indicate exactly
where you live such as, highway name and milepost number, boat harbor, pier and slip number, subdivision name
with lot and block or trailer park name and space number. If you live in rural Alaska, you may provide the
community name as your residence address.
If you have a different mailing address than your residence address, you may choose to keep your residence
address confidential. Confidential addresses are not released to the general public, but may be released to
government agencies or during election processes as set out in state law.
If you are temporarily out of state and have intent to return, you may maintain your Alaska residence as it
appears on your current record. If you provide a new residence address, it must be within Alaska. Active military
and military spouses are exempt from intent requirement.
• Proof of Identity – Your identity must be verified. If you have been issued a Social Security number, Alaska
Driver’s License, or Alaska State ID card, you MUST provide at least one number on Line 10 of the application. If
you have never been issued one of the identification numbers, please indicate so by checking the box on Line 10.
• Date of Birth – You MUST provide your date of birth.
2. Are you submitting this application by mail, by fax, or email? If so, and if you are not already registered to
vote in Alaska, your identity must be verified either at the time you register or the first time you vote. If you would
like to ensure that your identity is verified at the time you register, submit a copy of one of the below:
• Current and valid photo identification
• Driver’s license
• Passport
• State identification card
• Birth certificate
• Hunting and Fishing license
3. Have you been convicted of a felony? If so, you may register to vote only if you have been unconditionally
discharged. Provide a copy of your discharge papers with this application if available.
4. Political Affiliation. Write your political affiliation. Recognized political parties are parties who have gained
recognized political party status under Alaska Statute. Political groups are parties who have applied for recognized
political party status but have not met the qualifications. Alaska political affiliations are as follows:
Recognized Political Parties:
• Alaska Democratic Party
• Alaska Republican Party
• Alaskan Independence Party
Political Groups:
Other:
• Nonpartisan (not affiliated with a
political party or group)
• Undeclared (do not wish to
declare a political affiliation)
• Alaska Constitution Party
• Alaska Libertarian Party
• Green Party of Alaska
• Moderate Party of Alaska
• OWL Party
• Patriot’s Party of Alaska
• Progressive Party of Alaska
• UCES’ Clowns Party
• Veterans Party of Alaska
• Alliance Party of Alaska
Mail, fax or email (as a PDF, TIFF or JPEG attachment) your completed application to one of the offices listed below:
Region I Elections Office
PO Box 110018
Juneau AK 99811-0018
(907) 465-3021 Telephone
(907) 465-2289 – Fax
Toll Free 1-866-948-8683
electionsr1@alaska.gov
Region II Elections Office
Anchorage Office
2525 Gambell Street Suite 100
Anchorage AK 99503-2838
(907) 522-8683 – Telephone
(907) 522-2341 – Fax
Toll Free 1-866-958-8683
electionsr2a@alaska.gov
Matanuska-Susitna Office
North Fork Professional Building
1700 E. Bogard Road Suite B102
Wasilla AK 99654-6565
(907) 373-8952 – Telephone
(907) 373-8953 – Fax
Electionsr2m@alaska.gov
Region III Elections Office
675 7
th
Avenue Suite H3
Fairbanks AK 99701-4542
(907) 451-2835 – Telephone
(907) 451-2832 – Fax
Toll Free 1-866-959-8683
electionsr3@alaska.gov
Region IV Elections Office
PO Box 577
Nome AK 99762-0577
(907) 443-5285 – Telephone
(907) 443-2973 – Fax
Toll Free 1-866-953-8683
electionsr4@alaska.gov
Native Language Assistance
Toll Free 1-866-954-8683
Visit our website at: www.elections.alaska.gov
C03 (Rev. 01/29/2020)
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Form 1.: STATE OF ALASKA VOTER REGISTRATION APPLICATION (City of Homer)

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Completed 2 August 2020

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