Clear Form
New York State Voter Registration Form
Register to vote
With this form, you register to vote in elections in New
York State. You can also use this form to:
• change the name or address on your voter registration
• become a member of a political party
• change your party membership
• pre-register to vote if you are 16 or 17 years of age
To register you must:
• be a US citizen;
• be 18 years old (you may pre-register at 16
or 17 but cannot vote until you are 18);
•
not be in prison or on parole for a felony conviction (unless
parole pardoned or restored rights of citizenship);
• not claim the right to vote elsewhere;
• not found to be incompetent by a court.
Send or deliver this form
Fill out the form below and send it to your
county’s address on the back of this form,
or take this form to the office of your County
Board of Elections.
Mail or deliver this form at least 25 days before
the election you want to vote in. Your county will
notify you that you are registered to vote.
Questions?
Call your County Board of Elections
listed on the back of this form or
1-800-FOR-VOTE (TDD/TTY Dial 711)
Find answers or tools on our website
www.elections.ny.gov
Verifying your identity
We’ll try to check your identity before Election
Day, through the DMV number (driver’s license
number or non-driver ID number), or the last
four digits of your social security number,
which you’ll fill in below.
If you do not have a DMV or social security
number, you may use a valid photo ID, a current
utility bill, bank statement, paycheck, government
check or some other government document that
shows your name and address. You may include a
copy of one of those types of ID with this form—
be sure to tape the sides of the form closed.
If we are unable to verify your identity before
Election Day, you will be asked for ID when
you vote for the rst time.
中文資料:若您有興趣索取中文資料表格,
請電: 1-800-367-8683
1-800-367-8683
Información en español: si le interesa obtener este
formulario en español, llame al 1-800-367-8683
한국어: 한국어 양식을 원하시면
1-800-367-8683 으로 전화 하십시오.
It is a crime to procure a false registration or to furnish false information to the Board of Elections.
Please print in blue or black ink.
Are you a citizen of the U.S.?
Yes No
1
If you answer No, you cannot register to vote.
For board use only
Qualications
2
Yes No
A) Will you be 18 years of age or older on or before election day?
B) Are you at least 16 years of age and understand that you must be 18 years of
age on or before election day to vote, and that until you will be eighteen years of
age at the time of such election your registration will be marked “pending” and you
will be unable to cast a ballot in any election.
Yes No
If you answer No to both of the prior questions, you cannot register to vote.
Last name Sufx
Your name
3
First name Middle Initial
/ /
– –
M M D D Y Y Y Y
5
Gender
4
Birth date
More information
Items 5, 6 & 7 are optional
6
Phone
7
Email
Address (not P.O. box)
The address
where you live
8
Apt. Number
City/Town/Village
New York State County
Zip code
The address where
you receive mail
Skip if same as above
9
Address or P.O. box
P.O. Box
City/Town/Village
Zip code
Have you voted before? Yes No
11
What year?
Voting history
10
Your name was
Voting information
that has changed
12
Your address was
Skip if this has not changed
or you have not voted before
Your previous state or New York State County was
New York State DMV number
You must make 1 selection
Identication
13
Last four digits of your Social Security number
xxx – xx –
For questions, please refer to
Verifying your identity above.
I do not have a New York State driver’s license or a Social Security number.
Political party
You must make 1 selection
Political party enrollment is
optional but that, in order to
vote in a primary election of
a political party, a voter must
enroll in that political party,
unless state party rules allow
otherwise.
14
I wish to enroll in a political party
Democratic party
Republican party
Conservative party
Working Families party
Green party
Libertarian party
Independence party
SAM party
Other
I do not want to enroll in any political party
and wish to be an independent voter
No party
Afdavit: I swear or afrm that
• I am a citizen of the United States.
• I will have lived in the county, city or village
for at least 30 days before the election.
• I meet all requirements to register
to vote in New York State.
• This is my signature or mark in the box below.
• The above information is true, I understand that
if it is not true, I can be convicted and fined up
to $5,000 and/or jailed for up to four years.
Sign
I need to apply for an Absentee ballot.
Optional questions
15
16
Date
I would like to be an Election Day worker.
Rev. 12/09/19
Select your New York State County
