REGISTER
AND
VOTE
Page 1
DSBE·02/2021
Pennsylvania
Voter Registration Application
Register to vote
With this form, you can
register to vote in elections
in Pennsylvania.
You can also use this form to:
Change the information on your
Pennsylvania voter registration.
Register with a political party or change
the party you have selected.
If you are currently registered to vote in
Pennsylvania, you do not have to use this form
unless you have moved or changed your name.
To register you must:
Be a United States citizen for at least 30 days
before the next election.
Be a resident of Pennsylvania and your
election district for at least 30 days before
the next election.
Be at least 18 years of age on the day of the
next election.
Register online
Yo
u can also register to vote
on t he web.
Go to vote.pa.gov/Register.
Send or deliver this form
To be registered in the next election, mail or
deliver your application form to your county
voter registration office at least 15 days before
the next election.
Addresses for all Pennsylvania counties are
listed on page 2.
If your registration is accepted, you will receive
a Voter Registration Card from your county by
nonforwardable mail.
Your registration is not complete until
processed and accepted by your county voter
registration office.
If you do not receive your Voter Registration
Card within 7-10 days, contact your county
voter registration office.
Verifying your identity
When you vote for the first time in your election
district, you must show a form of identification.
For a complete list of acceptable forms of photo
and non-photo identification, visit
www.vote.pa.gov/ID
or call your County
Board of Elections or 1-877-868-3772.
In the military?
If you are on active duty or you are a hospitalized
or bedridden veteran, you can register at any
time. See
www.fvap.gov for more information.
College student in
Pennsylvania?
If you are a college student who attends college
in Pennsylvania, you can register where you live
while attending school.
For more information, see www.vote.pa.gov.
You may only register and vote in one place.
In prison or convicted of a
felony?
If you meet all other requirements, you may
register and vote if:
You are in prison awaiting trial but have not
been convicted.
You are in prison after being convicted of a
misdemeanor only.
You have been released from prison or a
halfway house after completing your term of
incarceration.
You are on probation or released on parole.
You are under house arrest.
You should register at the address where you
live, except that you cannot use a prison or
half-way house address for your registration.
See
www.vote.pa.gov for more information.
Información en español:
Si le interesa obtener este formulario en
español, llame al 1-877-868-3772.
For more information about
voting, visit our website:
www.vote.pa.gov.
Questions?
Call your County Voter
Registration Office
or call
1-877-868-3772.
PENALTY FOR FALSIFYING DECLARATION
Warning: If a person signs an official registration application knowing a statement
declared in the application to be false. makes a false registration, or furnishes false
information, the person commits perjury.
Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven
years. or a fine not exceeding $15,000, or both, at the discretion of the court.
Submitting an application containing false information may also subject a person to
other penalties, including loss of the right of suffrage, under state or federal law.
Confidentiality
If you decline to register to vote, the fact that
you declined will remain confidential, and will
be used for voter registration purposes only.
If you register to vote, the office at which you
register will remain confidential and will be
used for voter registration purposes only.
Page 2
PA-DOS VRAD 01.2021
Pennsylvania County Voter Registration Oce addresses
Adams
117 Baltimore St
Rm 106
Gettysburg PA 17325
(717) 337-9832
Allegheny
542 Forbes Ave
Ste 609
Pittsburgh PA 15219-2913
(412) 350-4500
Armstrong
Administration Bldg
450 E Market St
Ste 207
Kittanning PA 16201
(724) 548-3222
Beaver
810 Third St
Beaver PA 15009
(724) 770-4440
Bedford
200 S Juliana St
3rd Fl
Ste 301
Bedford PA 15522
(814) 623-4807
Berks
633 Court St
1st Fl
Reading PA 19601
(610) 478-6490
Blair
279A Loop Road
Hollidaysburg PA 16648
(814) 693-3287
Bradford
6 Court St
Ste 2
Towanda PA 18848
(570) 265-1717
Bucks
55 E Court St
Doylestown PA 18901-4318
(215) 348-6163
Butler
PO Box 1208
Butler PA 16003
(724) 284-5308
Cambria
200 S Center St
Ebensburg PA 15931
(814) 472-1464
Cameron
20 E Fifth St
Emporium PA 15834-1469
(814) 486-9321
Carbon
410 Center Ave
Jim Thorpe PA 18229-0170
(570) 325-4801
Centre
420 Holmes St
Willowbank Oce Bldg
Bellefonte PA 16823-1486
(814) 355-6703
Chester
601 Westtown Rd
Ste 150
PO Box 2747
West Chester PA 19380-0990
(610) 344-6410
Clarion
Administrative Building
330 Main St
Rm 104
Clarion PA 16214
(814) 226-4000 Ext 2006
Cleareld
212 E Locust St
Ste 106
Cleareld PA 16830
(814) 765-2642 ext 5053
Clinton
2 Piper Way
Ste 309
Lock Haven PA 17745
(570) 893-4019
Columbia
PO Box 380
Bloomsburg PA 17815-0380
(570) 389-5640
Crawford
903 Diamond Park
Meadville PA 16335
(814) 333-7307
Cumberland
1601 Ritner Highway
Ste 201
Carlisle PA 17013
(717) 240-6385
Dauphin
PO Box 1295
Harrisburg PA 17108-1295
(717) 780-6360
Delaware
Govt Center Bldg
201 W Front St
Media PA 19063-2728
(610) 891-4659
Elk
300 Center St
PO Box 448
Ridgway PA 15853-0448
(814)776-5337
Erie
140 W 6th St
Rm 112
Erie PA 16501
(814) 451-6276
Fayette
22 E Main St
Public Service Bldg
Uniontown PA 15401
(724) 430-1289
Forest
526 Elm St
Box 3
Tionesta PA 16353
(814) 755-3537
Franklin
157 Lincoln Way East
Chambersburg PA 17201-2211
(717) 261-3886
Fulton
116 W Market St
Ste 205
McConnellsburg PA 17233
(717) 485-6872
Greene
93 E High St
Rm 102
Waynesburg PA 15370
(724) 852-5230
Huntingdon
Bailey Building
233 Penn St
Huntingdon PA 16652-1486
(814) 643-3091 Ext 205
Indiana
825 Philadelphia St
Indiana PA 15701-3934
(724) 465-3852
Jeerson
155 Main St
Jeerson Place
Brookville PA
15825-1269
(814) 849-1693
Juniata
1 N Main St
PO Box 68
Miintown PA 17059
(717) 436-7706
Lackawanna
123 Wyoming Ave
2nd Floor
Scranton PA 18503
(570) 963-6737
Lancaster
PO Box 2139
Lancaster PA 17608
(717) 299-8293
Lawrence
430 Court St
New Castle PA 16101
(724) 656-2161
Lebanon
400 S 8th St
Municipal Bldg
Rm 209
Lebanon PA 17042
(717) 228-4428
Lehigh
17 S 7th St
Allentown PA 18101-2401
(610) 782-3194
Luzerne
20 N Pennsylvania Ave
Ste 207
Wilkes-Barre PA 18701
(570) 825-1715
Lycoming
48 W Third St
Williamsport PA 17701-9536
(570) 327-2267
McKean
500 W Main St
Smethport PA 16749
(814) 887-3203
Mercer
5 Courthouse
Mercer PA 16137-1227
(724) 662-7542
Miin
20 N Wayne St
Lewistown PA 17044
(717) 248-6571
Monroe
One Quaker Plaza
Rm 105
Stroudsburg PA 18360
(570) 517-3165
Montgomery
Voter Services
PO Box 311
Norristown PA 19404-0311
(610) 278-3280
Montour
253 Mill St
Danville PA 17821
(570) 271-3002
Northampton
Elections Division
669 Washington St
Easton PA 18042
(610) 829-6260
Northumberland
320 N 2nd St
Ste 1
Sunbury PA 17801
(570) 988-4208
Perry
PO Box 37
New Bloomeld PA 17068
(717) 582-2131 ext 4110
Philadelphia
520 N Columbus Blvd
Philadelphia PA
19123-4295
(215) 686-1590
Pike
506 Broad St
Milford PA 18337
(570) 296-3427
Potter
1 N Main St
Ste 204
Coudersport PA 16915
(814) 274-8467
Schuylkill
420 N Centre St
Pottsville PA 17901
(570) 628-1467
Snyder
PO Box 217
Middleburg PA 17842-0217
(570) 837-4207
Somerset
300 N Center Ave
Ste 340
Somerset PA 15501
(814) 445-1549
Sullivan
245 Muncy St
PO Box 157
Laporte PA 18626
(570) 946-5201 ext 7
Susquehanna
PO Box 218
31 Lake Ave
Montrose PA 18801
(570) 278-6697
Tioga
118 Main St
Wellsboro PA 16901
(570) 723-8230
Union
155 N 15th St
Lewisburg PA 17837-8822
(570) 524-8681
Venango
1174 Elk St
PO Box 831
Franklin PA 16323-0831
(814) 432-9514
Warren
204 4th Ave
Warren PA 16365
(814) 728-3406
Washington
100 W Beau St
Rm 206
Washington PA 15301
(724) 228-6750
Wayne
925 Court St
Honesdale PA 18431
(570) 253-5978
Westmoreland
2 N Main St
Ste 109
Greensburg PA 15601
(724) 830-3150
Wyoming
1 Courthouse Sq
Tunkhannock PA 18657
(570) 996-2226
York
28 E Market St
York PA 17401-1579
(717) 771-9604
For a listing of available email
addresses, go to
www.vote.pa.gov/county.
Page 3
DSBE·02/2021
Pennsylvania Voter Registration Application
Use black ink
1
Print your name
Last name
First name
Jr Sr II III IV
Middle name or initial
2
Eligibility
If you answer “No” to
either question, you cannot
register to vote.
Are you a citizen of the U.S.? Yes
Yes
No
Will you be 18 years or older
No
on or before election day?
3
Reason
5
4
About you
Phone and email are optional
and used if information is
missing on this form.
New registration
Change of name Change of address
Change of party
Federal or State employee registering in county of last residence
Birth date
Sex
M F Race (optional)
Phone
Email
Address (not P.O. Box) Apt. number
City/Town State PA Zip Code
Municipality County
I do not have a street address or permanent residence (use map on back)
Your address
If you do not have a street
address or a permanent
residence, or are a student,
see the instructions.
The address where
you receive mail
6
Same as above Address or P.O. Box
City/Town State Zip Code
Identification
If you have a Penn DOT number,
you must use it. If not, please provide
the last four digits of your Social
Security number.
See Verifying your identity.
7
PA driver's license or PennDOT ID card number
Last four digits of your Social Security number X X X - X X -
I do not have a PA driver’s license or a PennDOT ID card or a Social Security number.
Political party
To vote in a primary, you
must register with either the
Democratic or Republican party.
8
Democratic Republican Green Libertarian None (No Affiliation)
Other
Voting assistance
9
I require help to vote. I need this kind of assistance:
I require language help. My preferred language is:
If your name
or address has
changed
Skip if this is the first time you
are registering to vote.
10
Name on previous registration
Full previous address and county
PA Voter No. (if available) Year
Transfer Permanent Ballot Request
By checking the box, you are requesting that you continue to maintain your annual ballot request status
when updating your address.
Declaration
11
I declare that:
• I am a United States citizen and will have been a citizen for at
least 30 days on the day of the next election.
• I will be at least 18 years old on the day of the next election.
• I will have lived at the same address in Section 5 for at least
30days before the election.
• I am legally qualified to vote.
I affirm that this information is true. I understand that this
declaration is the same as an affidavit, and, if this information
is not true, I can be convicted of perjury, and fined up to
$15,000, jailed for up to seven years, or both.
Signature or mark
Print name
Today's date
Help with this form
Name of assistant
Fill in if someone helped you
with this form or witnessed you
make a mark for your signature.
12
Address
Phone Signature of assistant
click to sign
signature
click to edit
click to sign
signature
click to edit
Be a poll worker
If you check either of these boxes,
your county voter registration office
will contact you.
13
I would like to be a poll worker on Election Day.
I would like to be a bilingual interpreter on Election Day. I speak this language:
_________________________________________________________________________________________
Instructions for Section 5:
How to show your address on a map
If you live in a rural area and do not have a street address,
use the map to the right to show where you live.
with landmarks and road names.
If you are homeless, use the map to the right to show where you
spend most of your time.
How to fill in the map:
• Write the names of the roads or streets nearest to where you live.
• Draw an X to show where you live.
• Use a dot to show the location of landmarks, such as schools,
churches, or stores, and identify them by name.
Draw your map here. Example map. Do not use this map.
X
• Library
• Gas
station
School
Main St
Route 40
Fold here
Fold here
Your address
Place
First-class
stamp
here
Your County Voter Registration Office address:
Tape here
Tape here
Tape here
Fold, tape shut, and mail to your
County Voter Registration Office.
Do not use staples.
County Voter Registration Office addresses are listed on
page 2.
Page 4