NORTH CAROLINA VOTER REGISTRATION APPLICATION (elds in red text are required)
2020.02
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1 Indicate whether you are qualied to vote or preregister to vote based on U.S. cizenship and age.
Are you a cizen 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
Yes No
Will you be at least 18 years of age on or before elecon day?
Are you at least 16 years of age and understand that you must be 18 years of age on or before elecon 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.
3
Provide your date of birth and idenon informaon.
Last Name Sux
First Name
Middle Name
Date of Birth (MM/DD/YYYY)
/ /
State or Country of Birth
NC Driver License or NC DMV ID Number Last 4 Digits of Social Security Number
Check if you do not have
a driver license or
Social Security number.
State Voter Registran Number (Oponal: To
locate, check “Voter Lookup” at www.NCSBE.gov.)
4
Provide your residenal address - where you physically live.
Do not enter a P.O. Box or a mail drop locaon.
5
Provide a mailing address.
Address Number Street Name and Type
Address Line 2 (e.g., apartment, lot or unit number)
City State Zip Code
Do you receive
mail at your
residenal
address?
Yes No
If “No”, you are
required to
provide a mailing
address.
Mailing Address Line 1
Mailing Address Line 2
Mailing Address Line 3
City State Zip Code
County
Have you lived at this
address for 30 or more days?
Yes No
If “No”, date moved?
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 elecons to send you a voter card.
6
Provide your demographic informaon (oponal).
7
Provide your choice for polical party aliaon.
Gender
Male
Female
Race
African American/Black
American Indian/Alaska Native
Asian
Multiracial
Native Hawaiian/Pacific Islander
White
Other
Democratic Party
Constitution Party
Green Party
Libertarian Party
Republican Party
Unaffiliated
Other
___________________
If you select a party that is
not recognized in North
Carolina, you will be
registered as Unaffiliated.
Ethnicity
Not Hispanic/Latino
Hispanic/Latino
8
Complete if you are currently registered to vote in another NC county or in another state.
(This informaon will be used to cancel your previous voter registraon in the other county or state.)
First Name Used in Last Registraon Middle Name Used in Last Registraon Last Name Used in Last Registration Sux
Address Where You Were Last Registered City/State/Zip Code of Last Registraon County of Last Registran
9
Provide your contact informaon (oponal).
(This informaon is helpful if we need to contact you concerning your voter registraon. Your contact informaon may be disclosed as a public record.)
Area Code Phone Number Email Address Would you like to be contacted to be a poll worker?
Yes No
10
Sign below toest to your qualions to vote.
FRAUDULENTLY OR FALSELY COMPLETING THIS FORM IS A CLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES.
I aest, under penalty of perjury, that in addin to having read and understood the contents of this form, that: (1) I am a United States cizen, as indicated
above; (2) I am at least 18 years of age, or will be by the date of the general elecon; 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 elecn to vote; I shall have been a resident of North Carolina, this county, and precinct for 30 days before the date of the elecon in
which I intend to vote; (3) I will not vote in any other county or state aer submission of this form and if I am registered elsewhere, I am canceling that registran
at this me; 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 proban.
Signature Required Date
X
