Fillable Form 1: *VR-06-NCVRA0418 06w NORTH CAROLINA VOTER REGISTRATION (County Of Pitt)

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Form 1: *VR-06-NCVRA0418 06w NORTH CAROLINA VOTER REGISTRATION (County Of Pitt)

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BROWSE COUNTY OF PITT (NC) FORMS

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06w
*VR-06-NCVRA0418
*
NCSBOE 2018.04
NORTH CAROLINA VOTER REGISTRATION APPLICATION
(fields in red are required)
1
Indicate whether you are qualified to vote or preregister to vote based on U.S. citizenship and age.
Are you a citizen of the United States of America?
IF YOU CHECKED “NO” IN RESPONSE TO THIS CITIZENSHIP QUESTION, DO NOT SUBMIT THIS FORM. YOU ARE NOT QUALIFIED TO VOTE.
Yes No
Will you be at least 18 years of age on or before election day?
Yes No
Are you at least 16 years of age and understand that you must be 18 years of age on or before election day to vote?
IF YOU CHECKED ‘”NO” IN RESPONSE TO BOTH OF THESE AGE QUESTIONS, DO NOT SUBMIT THIS FORM. YOU ARE NOT QUALIFIED TO REGISTER OR PREREGISTER TO VOTE.
Yes No
2
Provide your full legal name.
(last name, first name and middle name)
3
Provide your date of birth and identification information.
Legal Last Name Suffix Date of Birth (MM/DD/YYYY)
/ /
State or Country of Birth
Legal First Name NC Driver License or NC DMV ID Number Last Four Digits of Social Security Number
Middle Name
Check if you do not have a driver
license or Social Security number.
State Voter Registration Number - Optional
(To locate, check “Voter Lookup” at www.NCSBE.gov.)
4
Provide your residential address - where you physically live.
(Do not enter a P.O. Bo
x
or a mail drop location. Your address determines your voting districts)
5
Provide a mailing address if you do not receive mail at your residential address.
Address Number Street Name and Type Mailing Address Line 1
Address Line 2 (e.g., apartment, lot or unit number) Mailing Address Line 2
City State Zip Code Mailing Address Line 3
County Have you lived at this address
for 30 or more days?
Yes No
If “No”, date moved? City State Zip code
No Physical Address?
If you do not have an address, use the space to the right to
illustrate where you normally live or sleep. Write in the names
of the nearest crossroads (or streets). Draw an X on the map
to show where you live or usually sleep.
IMPORTANT: You should also provide a valid mailing
address above to permit the board of elections to send you a
voter card
.
6
Provide your demographic information (optional).
7
Provide your choice for political party affiliation.
Gender
Ma le Female
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Political Party Preference
Democratic Party Republican Party
Green Party No party affiliation or Unaffiliated
Libertarian Party
Other ___________________________
If you enter a party that is not recognized in North Carolina, you will be registered as Unaffiliated.
Race
African American/Black American Indian/Alaska Native Asian
Multiracial Native Hawaiian/Pacific Islander White Other
8
Complete if you are currently registered to vote in another NC county or in another state.
(This information will be used to cancel your previous voter registration in the other county or state.)
First Name Used in Last Registration Middle Name Used in Last Registration Last Name Used in Last Registration Suffix
Address Where You Were Last Registered City/State/Zip Code of Last Registration County of Last Registration
9
Provide your contact information (optional).
(This information is helpful if we need to contact you concerning your voter registration. This information may be disclosed as a public record.)
Area Code Phone Number Email Address
10
Sign below to attest to your qualifications to vote.
FRAUDULENTLY OR FALSELY COMPLETING THIS FORM IS A CLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES.
I attest, under penalty of perjury, that in addition to having read and understood the contents of this form, that: (1) I am a United States citizen, as indicated above; (2) I am at
least 18 years of age, or will be by the date of the general election; or I am at least 16 years old and understand that I must be at least 18 years old on the day of the general
election to vote; I shall have been a resident of North Carolina, this county, and precinct for 30 days before the date of the election in which I intend to vote; (3) I will not vote in
any other county or state after submission of this form and if I am registered elsewhere, I am canceling that registration at this time; and (4) I have not been convicted of a felony,
or if I have been convicted of a felony, I have completed my sentence, including any probation.
Si
g
nature
Date
X
NORTH CAROLINA VOTER REGISTRATION APPLICATION INSTRUCTIONS
You may use this application to do any of the following:
Registration Deadline
Register to vote
Preregister to vote if between the ages of 16 and 17
Change party affiliation or unaffiliated status
Report a change of address within a county
Report a name change.
To be effective for an upcoming election, this application must be
received by your county board of elections office no later than 25
days before the date of the election. If mailed, the application
may be received later than the deadline if it is postmarked on or
before the deadline.
Same Day Registration: If you miss the voter registration
deadline, you may register and vote during the one-stop
absentee voting period (early voting) for the election. You must
complete a voter registration application in person at a one-stop
site in your county of residence and show proof of your current
residential address to an election official at the one-stop site.
Acceptable proof of residence documents include a NC drivers
license or other photo ID issued by a government agency or a
current utility bill, bank statement, government check, paycheck
or other government document that shows your name and
address.
If you are not registered to vote by election day, you will not be
eligible to vote in the election.
To qualify to vote:
You must be a citizen of the United States
You must be at least 18 years of age, or you will be 18 years
of age by the next general election and you are voting in the
primary, or
You must be between the ages of 16 or 17 and desire to
preregister to vote
You must have resided in North Carolina and in the precinct
in which you present to vote for at least 30 days prior to the
election
You must not be currently serving a felony sentence. If
previously convicted of a felony, you must have fully
completed your sentence, including probation and/or parole.
No special document is required.
Identification Requirements
National Voter Registration Act Statement
Registration ID — Under federal and state law, if you apply to
register to vote and do not provide a valid identification number
in Section 3 on this form, you must enclose a copy of one of
the following documents with this application:
A current and valid photo ID
A current utility bill, bank statement, government check,
paycheck, or other government document that shows
your name and address
If you do not provide a valid form of identification, you will be
asked to show ID the first time you present to vote.
If you are submitting this application to an NVRA agency or the
North Carolina Division of Motor Vehicles, the location or office
where you submitted the application will remain confidential and
will be used only for voter registration purposes. Public
assistance agencies, disability services agencies, the North
Carolina Division of Motor Vehicles, and unemployment services
agencies must offer you the opportunity to register to vote at the
initial application for service of assistance and during any
recertification, renewal or change of address. If you decline to
register to vote, the fact that you so declined will also remain
confidential. If you would like help completing the voter
registration application, the agency will help you. The decision
whether to seek or accept help is yours. You may fill out the
application form in private and return it to the agency that
provided you the form or you may mail or deliver the form to your
county board of elections office.
Applying to register or declining to register to vote will not affect
the amount of assistance provided. If you believe that someone
has interfered with your right to register to vote, or your right to
choose your own political party or other political preference, you
may file a complaint with the NC State Board of Elections &
Ethics Enforcement, P.O. Box 27255, Raleigh NC 27611-7255
or you may call the agency at 1-866-522-4723.
Submitting Your Form:
You must mail or deliver this application in person with your
original signature if you are registering to vote for the first time
in your county of residence or if you are changing your party
affiliation.
If you are changing your name or address within your current
county of registration, you may also fax or email a scanned
image of your signed application.
You may give your signed application to another person to
deliver on your behalf.
This form should be mailed, faxed, emailed or delivered in person to your county board of elections.
You may also mail the form to:
NC State Board of Elections & Ethics Enforcement
P.O. Box 27255
Raleigh, NC 27611-7255
For more information concerning voter registration and voting requirements, contact the State Board at:
1-866-522-4723 (phone) or elections.sboe@ncsbe.gov (email).
www.NCSBE.gov
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Form 1: *VR-06-NCVRA0418 06w NORTH CAROLINA VOTER REGISTRATION (County Of Pitt)

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Completed 18 July 2020

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