Mail-In Voter Registration Form
Massachusetts Official
William Francis Galvin
Secretary of the Commonwealth
Print all information in black ink. Follow above instructions for proper delivery.
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How to use this form
1. Confirm your citizenship.
2. Print your name: last name, first name, middle name or initial.
3. Print your former name, if applicable.
4. Print the address where you live now: number and street name or rural
route number and box number (do not provide a post office box number),
apartment number, city or town and full zip code. Use the map
†
at right if
you cannot otherwise identify your address.
5. Print the address where you receive all your mail, if it is different from the
address entered on #4.
6. Print your date of birth: month, day and year. If you are 16 or 17 years old,
you will be pre-registered until you are old enough to vote. You will be
notified by mail when you become eligible to vote.
7. Federal law requires that you provide your driver’s license number to
register to vote. If you do not have a current and valid Massachusetts driver’s
license, you must provide the last four digits of your social security number.
If you have neither, you must write “none” in the box.
8. It is optional to provide your telephone number. If you include your
telephone number and do not check “unlisted” it will be a public record.
9. Check a party, ‘no party’ or print a political designation (not a party).
10. Print the address where you were last registered to vote.
11. If a person is helping you because you are physically unable to sign this
form, that assisting person must print his or her name and address and has
the option to print his or her telephone number.
12. Read the oath.
13. Print today’s date.
14. Sign your name.
This form may be mailed or hand-delivered to your city or town hall. If mailed,
fold the form, tape it closed, place a first class stamp on it, print your city or
town name and zip code for that city or town hall and drop into any mailbox.
You can use this form to:
• register or pre-register to vote in Massachusetts; and/or
• update your name, address, and political party.
To register or pre-register to vote in Massachusetts you must:
• BE A U.S. CITIZEN; and
• be a Massachusetts resident; and
• be at least 16 years old.
Penalty for Illegal Registration: Fine of not more than
$10,000 or imprisonment for not more than five years or both.
-Massachusetts General Laws, chapter 56 section 8.
Identification To Be Provided
Section 7 requires you to include your driver’s license number or the last 4
digits of your social security number on this application. This information will
be verified through the Registry of Motor Vehicles and the Commissioner of
Social Security. If the information cannot be verified or you do not provide this
information, you must provide identification either with this application or at
your polling location when you go to vote. Sufficient identification includes a copy
of a current and valid photo identification, current utility bill, bank statement,
government check, paycheck or other government document showing your name
and address.
†
Using landmarks, draw the
location of the place where you
live if you cannot describe that
location as a number and street or
as a rural route and box number.
1
Check one: Are you a Citizen of the United States of America? ■ Yes ■ No NOTE: If you checked “no,” do not complete this form.
2
Full name: last name first name middle name or initial
Jr. Sr. II III IV
(circle one if appropriate)
3
Former name: last name first name middle name or initial
Jr. Sr. II III IV
(circle one if appropriate)
4
Address where you live now (street number / street name / rural route number & box number / apartment number / city or town / zip code):
5
Address where you receive all your mail (if different from #4):
6
Date of birth: month day year
7
Identification #: license # or last 4 digits of SSN
8
Telephone (optional): ■ Check if unlisted
9
Party enrollment or designation (check one): ■ Democratic ■ Republican ■ Libertarian
■ No Party (unenrolled) ■ Political Designation (not a political party):
10
Address at which you were last registered to vote(street number / street name / rural route number & box number / apartment number / city or town / zip code):
11
If the applicant is unable to sign this form, give the name, address and telephone number (optional) of the person helping the applicant:
name address telephone number (optional)
12
I hereby swear (affirm) that I am the person named above, that the above information is true, that I AM A CITIZEN OF THE UNITED STATES, that I am at least 16 years
old and I understand that I must be 18 years old to be eligible to vote, that I am not a person under a guardianship which prohibits my registering to vote, that I am not temporarily or
permanently disqualified by law from voting because of corrupt practices in respect to elections, that I am not currently incarcerated for a felony conviction, and that I consider this
residence to be my home. Signed under the penalty of perjury.
13
Today’s date: month day year
14
Signed: Sign your name here.
