Voter Registration Application/ 选民登记申请表
Before completing this form, review the General, Application, and State specic instructions./在完成本表格之前，请查看一般指引、申请表指引和州特别指引
。
PLEASE PROVIDE YOUR RESPONSES IN ENGLISH. / 请以英文提供答案。
Are you a citizen of the United States of America?
您是否是美国公民？
Yes
是
No
否
Will you be 18 years old on or before election day?
您在选举日或之前是否年满 18 岁？
Yes
是
No
否
If you check “No” in response to either of these questions, do not complete form.
如果您对任何一个问题的回答是“否”，请不要完成表格。
(Please see state-specic instructions for rules regarding eligibility to register prior to age 18.)
(请见有关未满 18 岁登记资格规定的州特别指引)
This space for oce use only. /
本栏仅供办公室使用。
1
Last Name / 姓(Circle one) / (圈一个)
Mr. /
先生
Mrs. /
夫人
Miss /
小姐
Ms. /
女士
First Name / 名 Middle Name(s) / 中间名 (Circle one) / (圈一个)
Jr./小 Sr./老
II III IV
2
Home Address / 家庭住址 Apt. or Lot # /
公寓或小区号码
City/Town / 城市/镇 State / 州 Zip Code / 邮政编码
3
Address Where You Get Your Mail If Dierent From Above / 您获得邮件但不同于上述地址的地址 City/Town / 城市/镇 State / 州 Zip Code / 邮政编码
4
Date of Birth/ 出生日期
Month / 月 Day / 日 Year / 年
5
Telephone Number (optional) / 电话号码 (可选)
6
ID Number (See Item 6 in the instructions for your state) /
身份证明号码 (参见所在州指引的第 6 项)
7
Choice of Party (see item 7 in the instructions for your State) /
政党选择 (参见所在州指引的第 7 项)
8
Race or Ethnic Group (see item 8 in the instructions for your State) /
种族或民族 (参见所在州指引的第 8项)
9
I have reviewed my state’s instructions and I swear/arm that: /
我已经阅读过我所在州的指引并宣誓/确认：
■ I am a United States citizen. / 我是美国公民。
■ I meet the eligibility requirements of my state and subscribe to any oath required. /
我符合我所在州的资格要求并同意所要求的任何誓言。
■ The information I have provided is true to the best of my knowledge under penalty of perjury. If I have provided
false information, I may be ned, imprisoned, or (if not a U.S. citizen) deported from or refused entry to the
United States. /
尽我所知，我所提供的资料属实，否则会受到伪证罪的处罚。如果我提供虚假资料，
我可能被罚款、监禁或（如果不是美国公民）驱逐出境或拒绝进入美国。
Please sign full name (or put mark) / 请签署全名（或标记）
Date / 日期:
Month / 月 Day / 日 Year / 年
If you are registering to vote for the rst time: please refer to the application instructions for information on submitting copies of valid identication documents with this form.
如果您是第一次登记投票：请参见申请表指引，以了解随附此表提交有效身份证明文件副本的有关信息。
Please ll out the sections below if they apply to you.
如果以下内容适合您，请填写。
If this application is for a change of name, what was your name before you changed it? / 如果本申请表是用于姓名变更，您改名前的姓名是什么？
A
Mr. / 先生
Mrs. / 夫人
Miss / 小姐
Ms. / 女士
Last Name / 姓 First Name / 名 Middle Name(s) / 中间名 (Circle one) / (圈一个)
If you were registered before but this is the rst time you are registering from the address in Box 2, what was your address where you were registered before?
如果您之前登记过，但这次是您以空格2中的地址第一次登记，则您以前登记的地址是什么？
B
Street (or route and box number) /街 (或路线和邮箱号)
Apt. or Lot # /
公寓或小区号码
City/Town/County / 城市/镇/郡 State / 州 Zip Code / 邮政编码
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.
如果您住在农村，没有街道号码，或您没有地址，请在地图上表示您住的地方。
C
■ Write in the names of the crossroads (or streets) nearest to where you live. / 写下离您住所最近的十字路口（或街道）名称。
■ Draw an X to show where you live. / 画一个 X 以表示您住的地方。
■ Use a dot to show any schools, churches, stores, or other landmarks near where you live, and write the name of the landmark. /
用点表示您住所附近的学校、教堂、商店或其他地标，并写下地标的名称。
Example / 例如
Public School / 公立学校
•
•
Grocery Store / 日杂店
Woodchuck Road/ 旱獭路
Ruta Nº. 2/ 2 号路线
X
NORTH / 北
If the applicant is unable to sign, who helped the applicant ll out this application? Give name, address and phone number (phone number optional).
如果申请人不能签名，谁帮助申请人填写了本申请表？请写明姓名、地址和电话号码 (电话号码为可选)。
D
Mail this application to the address provided for your State.
将本申请表邮寄至您所在州的地址。
Jr./小 Sr./老
II III IV
