MOISTEN AND SEAL
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
To register you must:
• be a US citizen;
• be 18 years old by the end of this year;
• not be in prison or on parole
for a felony conviction;
• not claim the right to vote elsewhere.
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.
Last name
First name
16
Apt. Number
I need to apply for an Absentee ballot.
I would like to be an Election Day worker.
Middle Initial
Sufx
City/Town/Village
Zip code
Zip code
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.
I do not have a New York State driver’s license or a Social Security number.
x x x – x x –
Last four digits of your Social Security number
Democratic party
Republican party
Conservative party
Green party
Working Families party
Independence party
Women’s Equality party
Reform party
Other
Address (not P.O. box)
Your address was
Your previous state or New York State County was
Your name was
New York State County
3
Have you voted before? Yes No
8
14
15
Your name
More information
Items 6 & 7 are optional
The address
where you live
The address where
you receive mail
Skip if same as above
Voting history
Voting information
that has changed
Skip if this has not changed
or you have not voted before
Identication
You must make 1 selection
For questions, please refer to
Verifying your identity above.
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.
Optional questions
Qualications
10
What year?
11
12
Address or P.O. box
P.O. Box
City/Town/Village
9
13
Birth date
Y Y Y YD DM M
/ /
4
6
Phone
– –
Sex M F
5
Sign
Date
Are you a citizen of the U.S.? Yes No
If you answer No, you cannot register to vote.
1
If you answer No, you cannot register to vote unless you will be 18 by the end of the year.
Will you be 18 years of age or
older on or before election day?
Yes No
2
New York State DMV number
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.
For board use only
中文資料:若您有興趣索取中文資料表格,
請電:
Información en español: si le interesa obtener este
formulario en español, llame al 1-800-367-8683
한국어: 한국어 양식을 원하시면
으로 전화 하십시오.
Email
7
I wish to enroll in a political party
I do not wish to enroll in a political party
No party
Rev. 04/2015
HAND WRITTEN SIGNATURE REQUIRED
(THIS MESSAGE WILL NOT PRINT)
