Fillable National Voter Registration Application Form For U.S. Citizens (BEN) (Election Assistance Commission)

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National Voter Registration Application Form For U.S. Citizens (BEN) (Election Assistance Commission)

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The National Voter Registration Application Form For U.S. Citizens (BEN) (Election Assistance Commission) form is 4 pages long and contains:

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Country of origin: US
File type: PDF

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



• 
• 





• 


• 




 


 









2
 

18
  18 
 1 — 




  A

 


 2 — 



 
 

2
B








C



 3 — 
2
2 
3 


 4 — 



 5 — 
 


 6 — 

6
  



 7 — 



 7 










 8 — 
 


 8
8

• 


• 
•  

• 
• 
• 

• 
 9 — 
 9

(1) 
(2) 9




D




  

Are you a citizen of the United States of America?
 
Will you be 18 years old on or before election day?




(Please see state-specific instructions for rules regarding eligibility to register prior to age 18.)
  
This space for office use only. /

1
Last Name /  First Name /  Middle Name(s) / 
2
Home Address / 
Apt. or Lot # /  
City/Town /  State / 
Zip Code / 
3
Address Where You Get Your Mail If Different From Above / 
City/Town /  State / 
Zip Code / 
4
Date of Birth/ 
 Day /  Year / 
5
Telephone Number (optional) / 
6
ID Number (See Item 6 in the instructions for your state) /
 
7
Choice of Party (see item 7 in the instructions for your State) /
 
8
Race or Ethnic Group (see item 8 in the instructions for your State) /
 
9
I have reviewed my state’s instructions and I swear/affirm that: /
 
■ I am a United States citizen. /
■ I meet the eligibility requirements of my state and subscribe to any oath required. / 

■ The information I have provided is true to the best of my knowledge under penalty of perjury. If I have pro-
vided false information, I may be fined, imprisoned, or (if not a U.S. citizen) deported from or refused entry
to the United States. / 


Please sign full name (or put mark) / 
Date / 
 Day /  Year / 
please refer to the application instructions for information on submitting copies of valid identification documents with this form.
 


If this application is for a what was your name before you changed it? /   
Last Name /  First Name /  Middle Name(s) / 
If you were what was your address where you were registered before?

B
Street (or route and box number) / 
Apt. or Lot # /  
City/Town/County /  State /  State / 
If you live in a rural area but do not have a street number, or if you have no address, please show on the map where you live.

C
■ Write in the names of the crossroads (or streets) nearest to where you live. / 
■ Draw an X to show where you live. /  
■ Use a dot to show any schools, churches, stores, or other landmarks near where you live, and write the name of the landmark. /

 

Example / 
Public School / 
•
•
Grocery Store / 


X

If the applicant is unable to sign, who helped the applicant fill out this application? Give name, address and phone number (phone number optional).



Yes/No/
Yes/No/
Mr./Mrs./Miss/Ms./
IIIIIIV
Mr./Mrs./Miss/Ms./
FIRST CLASS
STAMP
NECESSARY
FOR
MAILING
FOR OFFICIAL USE ONLY


  

 
Yes

No



Yes

No




  


1








  
  II III IV
2

 
  
3
   
4

  
5

6

 
7

 
8

 
9
 
■ 
■ 

■ 





  

 


  




   



B

 
  


C
■ 
■ 
■ 

 

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
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



  II III IV

FIRST CLASS
STAMP
NECESSARY
FOR
MAILING
FOR OFFICIAL USE ONLY
3
ট নির্ শাবলী

 08-31-2018
 —

 

6. 

 


 






7. 



8. 



 8 2
9. 


•  
• 

• 
• 




sos.alabama.gov/mtfelonies
•  


• 



 



 


P.O. Box 5616
Montgomery, AL 36103-5616

 03-01-2006
 — 30

6. 


 

 






 


15)
7. 












8.  
9. 

• 
• 
90
18
• 
• 
 

• 




PO Box 110017
Juneau, AK 99811-0017

 03-01-2006
 — 29

6. 


A.R.S. § 28-3165













4
ট নির্ শাবলী



7. 

 



 
  



8.  
9. 

• 
• 29


• 
18
• 


•  



1700 W. Washington, 7th Floor
Phoenix, AZ 85007-2888

 03-01-2006
 — 30

6. 












7. 



8.  
9.  

• 
• 2 

• 18

• 



• 

• 




 
P.O. Box 8111
Little Rock, AR 72203-8111

 06-18-2018
 — 

 
6. 



 





7. 







 
 





 




www.sos.ca.gov

8.  
9. 

•  
• 
• 
• 

•  


•  



5
ট নির্ শাবলী
 




1500 11th Street, 5th Floor
Sacramento, CA 95814

 
 — 





6. 












7.


8.  
9. 

• 
• 


• 


• 



1700 Broadway, Suite 270
Denver, Colorado 80290

09-03-2019
 — 
  
 
6. 


7. 




8.  
9. 

• 
• 

• 


• 




•  






P.O. 150470
  CT 06115-0470

 04-18-2018
 — 
4
10
6. 












7. 



8.  
9. 

• 
• 

• 

• 

• 






• 

6
ট নির্ শাবলী
• 




•   

• 






• 






905 S. Governors Ave., Suite 170
Dover, DE 19904

 11-07-2019
 — 




6. 




7. 



8.  
9. 

• 
• 
• 


•  


• 








• 
• 


 
1015 Half Street, SE, Suite 750
Washington, DC 20003

 11-30-2011
 — 29

6.



 

 





7. 



8. 


 
8 (2-
9. 

• 
• 


• 18
16

• 




• 



• 








 

e R.A. Gray Building
500 South Bronough St, Rm 316
Tallahassee, Florida 32399-0250
7
ট নির্ শাবলী
 
 02-01-2016
 —

 

 



6. 

















7. 



8. 

 
8 2-
9.  

• 
•  

• 18
18

• 

• 





2 Martin Luther King Jr. Drive
Suite 802 Floyd West Tower
Atlanta, Georgia 30334

 06-18-2006
 — 30

6. 




 



 



7. 

8. 

9. 

• 
• 
• 16

18
• 

• 




802 Lehua Avenue
Pearl City, HI 96782

 03-01-2006
 — 25

6. 



7. 



8.  
9.  

• 
• 30

• 18 
• 






P.O. Box 83720
State Capitol Bldg.
Boise, ID 83720-0080
8
ট নির্ শাবলী

 09-03-2019
 — 28

6. 
 





 

 




 

7. 




8.  
9. 




• 
• 30


• 
18
• 

• 




 








 
2329 S. MacArthur Boulevard
Springeld, IL 62704

 03-01-2006
 — 29

6. 






3-7-13-13)
7.  
8.  
9. 

• 
• 30

• 18

• 




302 West Washington Street,
Room E-204
Indianapolis, IN 46204-2743

 03-28-2008
 —
10
5
11*
15
 


*

 


www.sos.state.ia.us/pdfs/elections/
EDRbrochure.pdf.
6. 







7. 




 
8. 
9. 

• 
• 
• 17-1/2
18
9
ট নির্ শাবলী
• 


•  

• 

• 




Lucas Building-1st Floor
321 E. 12th Street
Des Moines, IA 50319

 02-01-2016
 — 21
 
6. 


 
  
 
  


 
  





(KSA 25-2309).
7. 



8.  
9.  

• 
• 
• 18

• 




• 

• 



1st Floor, Memorial Hall
120 SW 10th Ave.
Topeka, KS 66612-1594

 10-25-2013
 — 29

6. 



116.155)

 


7. 



8.  
9. 

• 
• 
• 28

• 
18
• 


 

• 

• 


 
140 Walnut Street
Frankfort, KY 40601-3240

 
 — 30 

6.



 








 


(a)
(b)



10
ট নির্ শাবলী
 


(R.S.
18:104154; 42 U.S.C. § 405).
7. 





8

 




 
• 










 






  
 

 



 





P.O. Box 94125
Baton Rouge, LA 70804-9125

 08-14-2012
 —  21




6. 







7. 




8.  
9.  

• 
• 

• 17
18 





101 State House Station
Augusta, ME 04333-0101

 06-26-2008
 — 21
9:00
6. 


 



 

4







 3-202,



7. 



8.  
9. 

• 
• 
• 18

• 

• 

11
ট নির্ শাবলী
• 







 
P.O. Box 6486
Annapolis, MD 21401-0486


09-03-2019
 — 20

6. 






(4) 




7. 







8.  
9. 


• 
• 

• 

• 

• 

• 
 


Elections Division, Room 1705
One Ashburton Place
Boston, MA 02108

 11-07-2019
 — 






6. 



 

 



 



7. 

8.  
9. 

• 
• 

• 


• 


















Michigan.gov/Vote


 

P.O. Box 20126
Lansing, MI 48901-0726

 12-31-2008
 —21
5:00

6.












12
ট নির্ শাবলী
7.  
8.  
9. 

• 
• 20

• 

• 18

• 




• 


• 



60 Empire Drive, Suite 100
St. Paul, MN 55103-1855

 05-07-2010
 — 30

6. 



7. 




8.  
9.  

• 
• 

30

• 
18

• 















• 


: 1998
2000
 




P.O. Box 136
Jackson, MS 39205-0136



 

  

 www.sos.ms.gov 


 09-12-2006
 — 28

6. 






115.155, RSMo







115.157, RSMo)
7. 



8.  
9.  

• 
• 
• 17-1/2
18
• 


•  


• 
• 


P.O. Box 1767
Jeerson City, MO 65102-1767
13
ট নির্ শাবলী

 11-07-2019
 — 



 






6. 









 



 

 


7. 

8.  
9. 

• 
• 18

• 30


• 

•  

• 








https://sosmt.gov/
Portals/142/Elections/Forms/
electionadministrators.pdf.






soselections@mt.gov








P.O. Box 202801
State Capitol
Helena, MT 59620-2801

 03-08-2018
 —


 6
6.  

 



7. 



8.  
9.  

• 
• 
• 18 

18 
• 



• 



Suite 2300, State Capitol Bldg.
Lincoln, NE 68509-4608


— 




 

 








14
ট নির্ শাবলী
6.  

 

 



 

 

7. 



 
 

8. 

9.  

• 
• 

• 



•  

• 


• 




 













 




101 North Carson Street
Suite 3
Carson City, NV 89701-4786



 





 
 



: www.nvsos.gov















 


 www.nvsos.gov.

 03-01-2006
 —
 



 10

 


2
3

 

www.state.nh.us/sos/clerks.htm

 

10


 03-28-2008
 — 21 

6. 




15
ট নির্ শাবলী



7. 












 


8.  
9. 

• 
• 18 

• 30


• 




 


PO BOX 304
Trenton, NJ 08625-0304

 03-01-2006
 — 28 

6. 


 
 
 
 







 


(§1-
5-19B, NMSA 1978)
7. 



8.  
9. 

• 
• 
• 18

• 



 





325 Don Gaspar, Suite 300
Santa Fe, NM 87503

 06-19-2014
 — 25

6.






4



7. 




8.  
9.  

• 
• 30
 

• 
3118


18
• 

•  

• 


 
40 North Pearl Street, Suite 5
Albany, NY 12207-2729

 03-01-2006
 — 25
 
25
5:00

6. 

 

16
ট নির্ শাবলী


7. 









8. 



 8 (2-)
9.  

• 
• 30


• 18

• 

• 


 
P.O. Box 27255
Raleigh, NC 27611-7255

 03-01-2006


 03-01-2006
 — 30 

6. 


 
3503.14)








7. 




8.  
9. 

• 
• 
• 18 

18


• 
 
• 




180 E. Broad Street — 15th Floor
Columbus, OH 43215

 09-14-2019
 — 25 

6. 





7. 

 
 

 


   


 


 




8.  
9.  

•  

• 

• 



 
•  


• 







17
ট নির্ শাবলী


Box 528800
Oklahoma City, OK 73152-8800

 03-01-2006
 — 21

6. 







 

7. 


8.  
9.  

• 
• 
• 18



141 State Capitol
Salem, OR 97310-0722


 — 

6. 






7. 


8. 

 
8 2-
9. 

• 

• 30


• 18




210 North Oce Bldg.
Harrisburg, PA 17120-0029



 09-03-2019
 — 30

6.  




 







7. 







 

8.  
9. 

• 
• 30

• 

•  


• 


 

50 Branch Ave.
Providence, RI 02904-2790

 03-01-2006
 — 30

6. 





18
ট নির্ শাবলী
 

7-5-170)
7. 



8. 



 8 2-
9. 

• 
• 
18
• 

• 

• 






• 


• 




P.O. Box 5987
Columbia, SC 29250-5987

 03-01-2006
 — 15

6. 





7. 



8.  
9. 

• 
• 
• 18
•  



• 



500 E. Capitol
Pierre, SD 57501-5070

 05-01-2020
 — 30

6.






2.2.116
7. 



8.  
9. 


•  
• 
• 

• 

 

 





• 



 
Tennessee Tower, Seventh Floor
312 Rosa L. Parks Ave.
Nashville, TN 37243-1102

 03-01-2006
 — 30

6. 






 


19
ট নির্ শাবলী
7. 



8.  
9. 

• 
• 

• 17 10
18
• 






• 





P.O. Box 12060
Austin, TX 78711-2060

 09-14-2019
 —

• 



• 
 

• 


• 



6. 









7. 







8.  
9.  

•  
• 

• 






• 

• 


• 

•  
 



P.O. Box 142325
Salt Lake City, UT 84114

 09-14-2019
 — 
5:00 

6. 


4





7. 

8. 
9. 

• 
• 
• 18

• 





 


II,42]
9



20
ট নির্ শাবলী



128 State Street
Montpelier, VT 05633-1101
 

— 


6. 



  

 II, §2,
 (1971).
7.  
8.  
9.  

• 
•  

•   
18
• 

•  


  
1100 Bank Street, 1st oor
Richmond, VA 23219

 09-14-2019
— 

 



6. 

 

 



7. 


8.  
9.  

•  
• 



• 

• 
 

• 

 




P.O. Box 40229
Olympia, WA 98504-0229
 
 09-12-2006
 — 21

6. 






7. 





8.  
9.  

• 
•  

• 18
17
18

• 



• 



Building 1, Suite 157-K
1900 Kanawha Blvd. East
Charleston, WV 25305-0770

 08-31-2018
 —







21
ট নির্ শাবলী






https://myvote.wi.gov
2. 









http://elections.wi.gov

6. 

 

 

7.  
8.  
9. 


•  
• 

• 
• 





• 


•  


• 







https://myvote.
wi.gov/en-US/MyMunicipalClerk




212 East Washington Avenue,
ird Floor
P.O. Box 7984
Madison, WI 53707-7984








 03-01-2006
 


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National Voter Registration Application Form For U.S. Citizens (BEN) (Election Assistance Commission)

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Completed 10 August 2020

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