Mail-In Voter Registration Form
Massachusetts Official
William Francis Galvin
Secretary of the Commonwealth
Print all information in black ink. Follow above instructions for proper delivery.
north
east
west
south
†
Using landmarks, draw the
location of the place where you
live if you cannot describe that
location as a number and street or
as a rural route and box number.
How to use this form
1. Check all the boxes that apply to you.
2. Print your name: last name, first name, middle name or initial.
3. Print your former name, if applicable.
4. Print the address where you live now: number and street name or rural
route number and box number (do not provide a post office box number),
apartment number, city or town and full zip code. Use the map
†
at right if
you cannot otherwise identify your address.
5. Print the address where you receive all your mail, if it is different from the
address entered on #4.
6. Print your date of birth: month, day and year.
7. Federal law requires that you provide your driver’s license number to
register to vote. If you do not have a current and valid Massachusetts driver’s
license, you must provide the last four digits of your social security number.
If you have neither, you must write “none” in the box.
8. It is optional to provide your telephone number. If you include your tele-
phone number and do not check “unlisted” it will be a public record.
9. Check a party, ‘no party’ or print a political designation (not a party).
10. Print the address where you were last registered to vote.
11. If a person is helping you because you are physically unable to sign this
form, that assisting person must print his or her name and address and has
the option to print his or her telephone number.
12. Read the oath.
13. Print today’s date.
14. Sign your name.
This form may be mailed or hand-delivered to your city or town hall. If mailed,
fold the form, tape it closed, place a first class stamp on it, print your city or
town name and zip code for that city or town hall and drop into any mailbox.
You can use this form to:
• register to vote in Massachusetts; and/or
• change your name or address for voter registration only; and/or
• join a party, change from one party to another or leave a party.
To register to vote in Massachusetts you must:
•
BE A U.S. CITIZEN; and
• be a Massachusetts resident; and
• be at least 18 years old on or before the next election.
Penalty for Illegal Registration: Fine of not more than
$10,000 or imprisonment for not more than five years or both.
-Massachusetts General Laws, chapter 56 section 8.
Check all that apply:
Are you a Citizen of the United States of America? Yes No
Will you be 18 years of age or older on or before Election Day? Yes No
NOTE: If you checked “no” to either of these questions, do not complete this form.
Full name:
Former name
(if applicable):
Address where you live now (street number, street name, rural route number and box number):
Address where you receive all your mail (if different from #4):
Date of birth: Identification #: Telephone (optional): ■ Check if unlisted
Party enrollment or designation (check one):
Democratic Republican Green-Rainbow
United Independent Party No Party (unenrolled) Political Designation (not a political party):
Address at which you were last registered to vote:
If the applicant is unable to sign this form, give the name, address and telephone number (optional) of the person helping the applicant:
I hereby swear (affirm) that I am the person named above, that the above information is true, that I AM A CITIZEN OF THE UNITED STATES, that I am not a person
under a guardianship which prohibits my registering to vote, that I am not temporarily or permanently disqualified by law from voting because of corrupt practices in respect to elections,
that I am not currently incarcerated for a felony conviction, and that I consider this residence to be my home. Signed under the penalty of perjury.
( )
last name first name middle name or initial
month day year
Jr. Sr. II III IV
(circle one if appropriate)
license # or last four digits of your Social Security #
Jr. Sr. II III IV
(circle one if appropriate)
street number / street name / rural route number and box number apartment number city or town zip code + 4-digit
street number / street name / rural route number and box number apartment number city or town zip code + 4-digit
street number / street name / rural route number and box number / post office box apartment number city or town state zip code + 4-digit
name address telephone number (optional)
Today’s date:
month day year
Signed:
Sign your name here.
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Miss Ms. Mrs. Mr.
last name first name middle name or initial
Miss Ms. Mrs. Mr.
Section 7 requires you to include your driver’s license number or the last 4
digits of your social security number on this application. This information will
be verified through the Registry of Motor Vehicles and the Commissioner of
Social Security. If the information cannot be verified or you do not provide this
information, you must provide identification either with this application or at
your polling location when you go to vote. Sufficient identification includes a copy
of a current and valid photo identification, current utility bill, bank statement,
government check, paycheck or other government document showing your name
and address.
Identification To Be Provided
