Are you interested in working on
Election Day? ☐ Yes ☐ No
Tennessee Mail-In Application For Voter Registration
You can use this form to:
register to vote in Tennessee or to change your name and/or address.
To register to vote:
you must be a U.S. citizen, AND
you must be a resident of Tennessee, AND
you must be at least 18 years old on/or before the next election, AND
you must not have been convicted of a felony, or if you have, your voting rights must have been restored.
If you register by mail, you must vote in person the rst time you vote after registering.
MAIL OR HAND DELIVER THIS FORM TO YOUR COUNTY ELECTION COMMISSION.
Go to: http://tnsos.org/elections/election_commissions.php to nd your County Election Commission address.
Instructions / checklist:
☐ Please PRINT with a blue or black INK pen (not felt tip).
☐ Provide the information in boxes 1-10 below, read and answer the VOTER DECLARATION in box 11, and sign by the
“X” in box 12.
☐ An application for voter registration must be postmarked or hand delivered to the proper county election commission
ofce at least 30 days before an election.
☐ Voter registration records are public records, open to inspection by any citizen of Tennessee, excluding social security
numbers.
☐ To ensure a more condental mailing process of this form, the applicant is encouraged to place the voter
registration application in an envelope addressed to the county election commission.
Names of persons selected for jury service in state court are not chosen from permanent voter registration records.
If you are qualied and the information on your form is complete, we will add your name to the county’s voter rolls.
We will then mail you a voter registration card. This card will tell you where to vote.
Federal or Tennessee State Government Issued Photo ID Is Required To Vote Unless Exception Applies.
LAST NAME FIRST NAME MIDDLE NAME SUFFIX SEX RACE (OPTIONAL)
☐ M ☐ F
ADDRESS WHERE YOU GET YOUR MAIL (IF DIFFERENT THAN ABOVE) E-MAIL (OPTIONAL)
DATE OF BIRTH CITY AND STATE OF BIRTH SOCIAL SECURITY # PHONE #
WARNING: Giving false information to register to vote or attempting to register
when not qualied is a felony punishable by not less than two (2) years nor more
than twelve (12) years imprisonment or a ne of $5,000 or both.
(required under T.C.A. § 2-2-116 for
purposes of identication and to
avoid duplicate registration)
X
Signature (or mark) of Applicant Date
If applicant is unable to sign, provide signature of person who signed for applicant.
Signature of Person Assisting
Address
Are you a citizen of the United States? ☐ Yes ☐ No
Will you be 18 years of age or older on or before Election Day? ☐ Yes ☐ No
If you answered "No" in response to either of the above,
do not complete this form.
ADDRESS WHERE YOU LIVE (DO NOT GIVE A P.O. BOX) APT. # CITY COUNTY STATE ZIP CODE
NAME AND ADDRESS ON LAST VOTER REGISTRATION
NAME ADDRESS
CITY COUNTY STATE ZIP
VOTER DECLARATION: I, being duly sworn on oath (or
afrmation) declare that the above address is my legal residence
and that I plan to remain at such residence for an undetermined
period of time and say that to the best of my knowledge and
belief all of the statements made by me are true.
1. Are you a resident of the State of Tennessee?
2. Have you ever been convicted of a crime which
is a felony in this state, by a court in this state,
a court in another state, or a federal court?
Yes No
____ ____
____ ____
ss-3010 (Rev. 10/15)
FOR COUNTY ELECTION COMMISSION USE ONLY
Mail Reg # Approved
Effective Date P/A
District Precinct Ward
5
3
2
4
1
6
8
10
11
12
9
7
