1
Are you at least 16 years old? l Yes l No
Are you a U.S. citizen? l Yes l No If you answer NO to either question, do not complete this form.
2
Check boxes that apply and complete Items 3–12.
l New Registration l Name Change l Party Aliation Change l Address Change
3
Last Name First Name Middle Sux
4
Sex: l Male l Female
5
Month Date Year
Birth Date:
6a
MARYLAND Driver’s License or MVA ID Number MANDATORY (If you have neither see instructions)
6b
Social Security Number (last 4 digits)
6c
l Check here if you do not have either a current, valid Maryland
driver’s license / MVA ID card or a Social Security Number
7
Maryland Street Number Street Name Apt. No. City or Town Zip Code County
Residence
Address:
8
Mailing Address (if dierent from Item 7)
9
Party (check one): l Democratic Party l Republican Party l Green Party l Libertarian Party l Constitution Party
l Unaliated (independent of any party) l Other – Specify __________________________________
10
CONTACT INFORMATION
Daytime Phone: Email (optional):
11
l Check here if you would like information on polling place assistance for elderly, disabled or voters unable to write or read the ballot.
l Check here if you would like information on working as an election judge for your County Board of Elections.
12
Under penalty of perjury, I hereby swear or arm: I am a U.S. citizen. n I am a Maryland resident. n I am at least 16 years old. n I have not been convicted of buying or selling votes. n I have not been
convicted of a felony, or if I have, I have completed serving a court-ordered sentence of imprisonment, including any term of parole or probation for the conviction. The information in this application is
true to the best of my knowledge, information and belief.
Signature (required)
X
Date
VOTER REGISTRATION APPLICATION PLEASE COMPLETE IN BLACK INK
l Check here if you reside in Baltimore City.
TO REGISTER, YOU MUST
n Be a U.S. citizen;
n Be a Maryland resident;
n Be at least 16 years old*;
n Not have been found by a court to be incapable of voting by reason of
mental disability;
n Not have been convicted of buying or selling votes;
n Not have been convicted of a felony, or if you have, you have
completed serving a court-ordered sentence of imprisonment,
including any term of parole or probation for the conviction.
*You may register to vote if you are at least 16 years old but cannot vote
unless you will be at least 18 years old by the next general election.
DEADLINE INFORMATION
n This application must be postmarked no later than 21
days before an election.
n If your application is complete and you are found to be qualied, a
Voter Notication Card will be mailed to you.
n The submission of this form to an individual other than an ocial,
employee, or agent of a County Board of Elections does not assure
that the form will be submitted or led in a timely manner.
YOU CAN USE THIS FORM TO
n Register to vote in federal, state, county, and municipal elections in
Maryland.
n Change your name, address, or party aliation.
INSTRUCTIONS
n If you do not have a current, valid Maryland driver’s license or MVA ID
card, you must enter the last 4 digits of your social security number.
The statutory authority allowing ocials to request the last 4 digits
of your social security number is Election Law Article, § 3-202. The
number will only be used for registration and other administrative
purposes. It will be kept condential.
n Complete Items 1–11 in Voter Registration Application. Sign and date
Item 12. If you are registered to vote in another Maryland county or
another state, you must complete Items A–B in Last Voter Registration.
n You must register with a party if you want to take part in that partys
primary election, caucus or convention. Check one box only.
n Address and mail the application to your County Board of Elections,
using the list on the back panel.
A
Name Last Name Title (Jr., Sr., etc.) First Name Middle Name Date of Birth
on Last
Registration:
B
Address Street Number Street Name Apt. No. City or Town Zip Code 4UBUF
on Last
Registration:
LAST VOTER REGISTRATION INFORMATION if applicable)
MARYLAND VOTER REGISTRATION APPLICATION
After This Form Is Filled Out, You Must Sign And Mail It To Your County Board of Elections.
It Cannot Be Processed If It Is Faxed or E-mailed, Because It Requires An Original Signature.
!
Maryland State Board of Elections SBE 03-202-1 Rev 06/10 Internet VRA
MARYLAND VOTER REGISTRATION APPLICATION
WARNING
Giving false information to obtain voter registration is
perjury and punishable by a ne of up to $1,000, or by
imprisonment for up to 5 years, or both.
PERSONAL RECORDS NOTICE/CONFIDENTIALITY
This form collects personal information for voter
registration purposes. If you are not registered to vote
and you refuse to provide this information, you will not be
allowed to vote in Maryland. You may update your voter
registration at any time at your County Board of Elections.
Except for items specied as condential, voter registration
records are generally available for public inspection; they
may also be shared with jury commissioners/clerks or
other government agencies as provided by law. The law
prohibits use of voter registration records for commercial
solicitation purposes. If you decline to register to vote, that
fact will remain condential and will be used only for voter
registration purposes.
If you register to vote, the identity of the oce at which the
application is submitted will remain condential and will be
used only for voter registration purposes.
QUESTIONS
Visit the State Board of Elections website at www.elections.
state.md.us to verify your registration, nd your polling
place, and nd out other important information. If you have
any questions, call your County Board of Elections or the
State Board of Elections at the numbers listed on the back
of the application.
If you register to vote, the identity of the oce at which the
application is submitted will remain condential and will be
used only for voter registration purposes.
Large type Voter Registration
Applications available upon
request to your County Board
of Elections or the State Board
of Elections.
!
Allegany County
701 Kelly Road, Suite 213
Cumberland, MD 21502-2887
301-777-5931
Anne Arundel County
P.O. Box 490
Glen Burnie, MD 21060-0490
410-222-6600
Baltimore City
Charles L. Benton Bldg.
417 E. Fayette Street, Rm. 129
Baltimore, MD 21202-3432
410-396-5550
Baltimore County
106 Bloomsbury Avenue
Baltimore, MD 21228
410-887-5700
Calvert County
P.O. Box 798
Prince Frederick, MD 20678-0798
410-535-2214
DC Line 301-855-1376
Caroline County
Health & Public Services Bldg.
403 S. Seventh Street, Suite 247
Denton, MD 21629-1378
410-479-8145
Carroll County
300 S. Center Street, Rm. 212
Westminster, MD 21157-5248
410-386-2080
Cecil County
200 Chesapeake Blvd.
Suite 1900
Elkton, MD 21921-6395
410-996-5310
Charles County
P.O. Box 908
La Plata, MD 20646-0908
301-934-8972
301-870-3167
Dorchester County
501 Court Lane, Rm. 105
P.O. Box 414
Cambridge, MD 21613-0414
410-228-2560
Frederick County
Winchester Hall
12 E. Church Street
Frederick, MD 21701-5447
301-600-8683
Garrett County
Public Service Center
2008 Maryland Highway, Suite 1
Mountain Lake Park, MD 21550-6349
301-334-6985
Harford County
133 Industry Lane
Forest Hill, MD 21050-1621
410-638-3565
Howard County
P.O. Box 6800
Columbia, MD 21045-6800
410-313-5820
Kent County
135 Dixon Drive
Chestertown, MD 21620-1141
410-778-0038
Montgomery County
P.O. Box 4333
Rockville, MD 20849-4333
240-777-8500
TDD 800-735-2258
Prince Georges County
16201 Trade Zone Ave., Suite 108
Upper Marlboro, MD 20774
301-430-8020
Queen Anne’s County
P.O. Box 274
Centreville, MD 21617-0274
410-758-0832
St. Mary’s County
P.O. Box 197
Leonardtown, MD 20650-0197
301-475-7844 ext. 1610
Somerset County
P.O. Box 96
Princess Anne, MD 21853-0096
410-651-0767
Talbot County
P.O. Box 353
Easton, MD 21601-0353
410-770-8099
Washington County
35 W. Washington Street
Room 101
Hagerstown, MD 21740-4833
240-313-2050
Wicomico County
P.O. Box 4091
Salisbury, MD 21803-4091
410-548-4830
Worcester County
100 Belt Street
Snow Hill, MD 21863-1300
410-632-1320
County Board of Elections
State Board of Elections • P.O. Box 6486 • Annapolis, MD 21401-0486 • www.elections.state.md.us • 800-222-8683 • MD Relay Service (800) 735-2258
Maryland State Board of Elections SBE 03-202-1 Rev 06/10 Internet VRA
After This Form Is Filled Out, You Must Sign And Mail It To Your County Board of Elections.
It Cannot Be Processed If It Is Faxed or E-mailed, Because It Requires An Original Signature.
!
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