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 Aliation Change l Address Change
3
Last Name First Name Middle Sux
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 dierent from Item 7)
9
Party (check one): l Democratic Party l Republican Party l Green Party l Libertarian Party l Constitution Party
l Unaliated (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 arm: 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 qualied, a
Voter Notication Card will be mailed to you.
n The submission of this form to an individual other than an ocial,
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 aliation.
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 ocials 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 condential.
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 party’s
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
