NJ Division of Elections - 6/22/12
Check boxes
o
New Registration
o
Address Change
o
Political Party Afliation
that apply:
o
Name Change
o
Signature Update or Non-afliation Change
Do you wish to declare a political party afliation?
o
Yes, the party name is
.
(Optional)
o
No, I do not wish to be afliated with any political party.
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.
Are you a U.S. Citizen? o Yes o No
(If No, DO NOT complete this form)
Date of Birth
NJ Driver’s License Number or MVC Non-driver ID Number
Last Name
First Name
Middle Name or Initial
Sufx
(Jr., Sr., III)
Home Address (DO NOT use PO Box)
Apt.
Municipality
County Zip Code
Will you be 18 years of age by the next election? o Yes o No
(If No, DO NOT complete this form)
Mailing Address if different from above
Last Address Registered to Vote (DO NOT use PO Box)
Former Name if Making Name Change
b. E-Mail Address (Optional)
Gender
o
Female
o
Male
Apt.
Municipality
County
Zip Code
Apt.
Municipality
County
Zip Code
8
10
2
3
4
5
6
7
Signature: Sign or mark and date on lines below
11
9
If applicant is unable to complete this form, print the
name and address of individual who completed this form.
Name
Date
Address
Clerk
Registration #
Ofce Time Stamp
o by mail
o in person
o
“I swear or afrm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”
l I will have resided in the State and county
at least 30 days before the next election
l I am not on parole, probation or serving a
sentence due to a conviction for an indictable
offense under any federal or state laws
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
Declaration - I swear or afrm that:
l I am a U.S. Citizen
l I live at the above address
l I will be at least 18 years old
on or before the next election
FOR OFFICIAL
USE ONLY
1
Date
State
State
State
New Jersey
Voter Registration Application
76
Please print clearly in ink. All information is required unless marked optional.
Need More Information? Check boxes below if you would like to receive more information about:
o
voting by mail
o
polling place accessibility
o
available election materials in
o
becoming a poll worker
o
voting if you have a disability,
this alternative language:
including visual impairment
For further information visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837)
Important Instructions for sections 5, 6 and 10
5) Registrants who are submitting this form by mail and are registering to vote for the rst time: If you do not have any of the
information required by section 5, 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.
6) If you are homeless, you may complete section 6 by providing a contact point or the location where you spend most of
your time.
10) You may declare a political afliation or you may declare to be unafliated, regardless of any prior party afliation.
Completing section 10 is OPTIONAL and will not affect the acceptance of your voter registration application.
a. Day Phone Number (Optional)
X
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