Fillable Form 3: 06w NORTH CAROLINA VOTER REGISTRATION APPLICATION (Haywood County NC)

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Form 3: 06w NORTH CAROLINA VOTER REGISTRATION APPLICATION (Haywood County NC)

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  • 27 check-boxes
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File type: PDF

U.S.A. forms for Haywood County NC

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NORTH CAROLINA VOTER REGISTRATION APPLICATION (elds in red text are required)
2020.02
06w
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 idenon 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 Registran 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
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 Registran
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 toest to your qualions 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 addin 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 elecn 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 registran
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 proban.
Signature Required Date
X
NORTH
APPLICATION INSTRUCTIONS
Use this application to: (1) register to vote; (2) preregister to vote if between the ages of 16 and 17; (3) change party affiliation or
unaffiliated status; (4) report a change of address within a county; or (5) report a name change.
Specific Instructions for Each Numbered Section of the Application:
1
Indicate whether you are qualified to vote or preregister to vote: (1) you must be a citizen of the United States; (2) 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; (3) 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; (4) you must not be currently serving a
felony sentence; and (5) if previously convicted of a felony, you must have fully completed your sentence, including
probation and/or parole. No special document is required.
2
Provide your full legal name. If your name has changed, this form will be used to update your current voter registration.
3
You are required to provide your date of birth. If you have a NC driver license or non-operator’s identification number,
provide this number. If you do not have a NC driver license or ID card, then provide the last four digits of your social security
number. If you have neither a NC driver license, NC DMV ID card or a social security number and you are registering to vote
for the first time in North Carolina, attach a copy of a current utility bill, bank statement, government check, paycheck, or
other government document that shows your name and address to this application.
4
Provide the address of your residence (where you physically live) as of the date of your application. In this section, do not
list a post office address or a location where you only receive mail. If you have moved to this residence within the past 30
days, provide the date of your move. If you do not have a traditional address, draw a picture in the space provided on this
form of your usual sleeping location. Be descriptive and note any nearby streets or physical buildings.
5
If you do not receive mail at your residential address, you must provide a mailing address.
6
This section asks for your gender, race, and ethnicity. You are not required to provide this information.
7
This section asks that you designate how you would like to be affiliated. You may choose to affiliate with any recognized
political party in North Carolina or you may opt to be registered as Unaffiliated. If you are applying for new registration in
the county and leave the party affiliation section blank, you will be registered as Unaffiliated.
8
If you are currently registered in another North Carolina county or another state, please provide your name and previous
address used on that prior registration. This information will be used to cancel your registration in the other county or state.
9
At your option, provide your phone number and email address.
10
You must sign this form. Only the person applying for registration is eligible to sign (or place your mark on) this form. If you
are applying for new registration in your county of residence, you must mail your original signature on this form.
National Voter Registration Act Statement: 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, 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. If you are changing your name, address or party affiliation within your current
county of registration, in addition to mail, you may also fax or email a scanned image of your signed application. If you give your
signed application to another person or organization to submit on your behalf, be sure the person or organization can commit to
timely submitting your application to the proper board of elections.
Voters will not be required to show photo ID when they vote in the primary election on March 3, 2020. In a
December 31 order, a federal district court blocked North Carolina’s voter photo ID requirement from taking effect. The injunction
will remain in place until further order of the court.
Haywood CountyBoardofElections
63 Elmwood Way, Ste A
Waynesville, NC 28786
MAIL or DELIVER:
FAX:
E-MAIL:
(828) 452 - 6750
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Form 3: 06w NORTH CAROLINA VOTER REGISTRATION APPLICATION (Haywood County NC)

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Completed 23 April 2021

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