1
Check all boxes that apply:
o
New Registration
o
Name Change
o
Political Party Aliation
o
Address Change
o
Signature Update
o
Vote By Mail
NJ Division of Elections - 01/09/20
New Jersey
Voter Registration Application
Important Instructions for sections 7, 8, 13 and 14
7) Registrants who are submitting this form by mail and are registering to vote for the rst time: If you do not supply any of the information
required by section 7, or the information you provide cannot be veried, you will be asked to provide a COPY of a current and valid
photo ID, or a document with your name and current address on it to avoid having to provide identication at the polling place.
Note: ID Numbers are Condential and will not be released by any governmental agency. Any person who uses such numbers
illegally shall be subject to criminal penalties.
8) If you are homeless, you may complete section 8 by providing a contact point or the location where you spend most of your time.
13) You may declare a political party aliation or you may declare to be unaliated, regardless of any prior party aliation. If you are a
previously aliated voter who wants to change political party aliation or become unaliated, you must le this form no later than
55 days before the primary election in order to vote in the primary election. Completing section 13 is OPTIONAL and will not aect
the acceptance of your voter registration application.
14) If you wish to receive a Mail-In Ballot for all future elections, mark the appropriate box in section 14. You will continue to receive
Mail-In Ballots for all future elections until you request otherwise in writing to your County Clerk’s oce.
Need More Information? Check boxes below if you would like to receive more information about:
o
voting by mail
o
polling place accessibility
o
voting if you have a disability, including visual impairment
o
becoming a poll worker
o
available election materials in this alternative language:
Are you a U.S. Citizen? o Yes o No
(If No, DO NOT complete this form)
Date of Birth (MM / DD / YYYY)
Last Name
First Name
Middle Name or Initial
Sux
(Jr., Sr., III)
Are you at least 17 years of age? o Yes o No
(If No, DO NOT complete this form)
Gender (Optional)
o
Female
o
Male
Do you wish to declare a political party aliation?
o
Yes, the party name is
.
(Optional)
o
No, I do not wish to be aliated with any political party.
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2
4
5
8
Clerk
Registration #
Oce Time Stamp
o by mail
o in person
FOR OFFICIAL
USE ONLY
Home Address (DO NOT use PO Box)
Apt.
Municipality (City/Town) County State Zip Code
9
10
Please print clearly in ink. All information is required unless marked optional.
Former Name if Making Name Change
11
Day Phone Number (Optional)
E-Mail Address (Optional)
6
Request for Mail-In Ballot for all future elections (Optional)
o
I wish to receive a Mail-In Ballot for all future elections until I request otherwise in writing to the County Clerk’s oce.
o
Mail my ballot to the following address if dierent from Mailing Address above.
14
Mailing Address if dierent from above
Apt.
Municipality (City/Town)
Zip Code
State
Declaration - I swear or arm that:
l I am a U.S. Citizen
l I live at the above home address
l I am at least 17 years old, and understand
that I may not vote until reaching the age of 18
l I will have resided in the State and county
at least 30 days before the next election
l I am not serving a sentence of incarceration
as the result of a conviction of any indictable
oense under the laws of this or another
state or of the United States.
l I understand that any false or fraudulent
registration may subject me to a ne of up
to $15,000, imprisonment up to 5 years, or
both pursuant to R.S. 19:34-1
Signature of Registrant: Sign or mark and date on lines below
If applicant is unable to complete this form, print the
name and address of individual who completed this form.
Name
Date (MM / DD / YYYY) / /
Address
Date / /
(MM / DD / YYYY)
X
If you DO NOT have a NJ Driver’s License or MVC Non-Driver
ID, provide the last 4 digits of your Social Security Number.
NJ Driver’s License Number or MVC Non-driver ID Number
7
o
“I swear or arm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __
/ /
Mailing Address (If dierent from Home Address)
Apt.
Municipality (City/Town) County State Zip Code
Last Address Registered to Vote
(DO NOT use PO Box)
Apt.
Municipality (City/Town) County State Zip Code
Muni Code #
Party
Ward
District
3
12
68
