8/4/2019 NY State Voter Reg English

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New York State Voter Registration Form

Register to voteWith this form, you register to vote in elections in

New York State. You can also use this form to:

• change the name or addresson 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 parolefor a felony conviction;

• not claim the right to vote elsewhere.

Send or deliver this formFill 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 CountyBoard of Elections.

Mail or deliver this form at least 25 days beforethe election you want to vote in. Your county willnotify you that you are registered to vote.

Questions?Call your County Board of Electionslisted on the back of this form or1-800-FOR-VOTE (TDD/TTY Dial 711)

Find answers or tools on our website

www.elections.state.ny.us

Verifying your identityWe’ll try to check your identity before ElectionDay, through the DMV number (driver’s licensenumber or non-driver ID number), or the lastfour 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, governmentcheck or some other government document thatshows your name and address. You may includea 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 beforeElection Day, you will be asked for ID when

you vote for the first time.

Información en español: si le interesa obtener este

formulario en español, llame al 1-800-367-8683

Last name

First name

15

Apt. Number

I need to apply foran Absentee ballot (optional).

I would like to be anElection Day worker (optional).

Middle Initial

Suffix

City/Town/Village

Zip code

Zip code

Affidavit: I swear or affirm that• I am a citizen of the United States.

• I will have lived in the county, city or villagefor at least 30 days before the election.

• I meet all requirements to registerto vote in New York State.

• This is my sign .wolebxobehtnikramroeruta

• The above information is true, I understand thatif it is not true, I can be convicted and fined upto $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

I do not wish to enroll in a 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

7

13

14

Your name

More information

The addresswhere you live

The address whereyou receive mailSkip if same as above

Voting history

Voting informationthat has changedSkip if this has not changed

or you have not voted before

IdentificationYou must make 1 selection

For questions, please refer toVerifying your identity above.

Political partyYou must make 1 selection

To vote in a primary election,

you must be enrolled in oneof these listed parties —except the Independence Party,

which permits non-enrolledvoters to participate in certainprimary elections.

Optional questions

Qualifications

9 What year?10

11

Address or P.O. box

P.O. Box

City/Town/Village

8

12

Birth date Y Y Y YD D/ /M M4 Sex M F5

Telephone (optional) – –6

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 orolder on or before election day? Yes No2

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: 1-800-367-8683

한국어: 한국어 양식을 원하시면

1-800-367-8683 으로 전화 하십시오.

MOISTEN AND SEAL

   E  n  g   l   i  s   h    6

   /   1   1

Conservative party

Working Families party

Independence party

Green party

8/4/2019 NY State Voter Reg English

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   E  y  e  c  o l  o  r

 I  f  y  o  u   w  o  u l  d l i  k  e  t  o  b  e  a  n  o  r  g  a  n  a  n  d  t i  s  s  u  e  d  o  n  o  r ,  y  o  u   m  a  y  e  n  r  o l l i  n

  t  h  e   N   Y  S   D  e  p  a  r  t   m  e  n  t  o  f   H  e  a l  t  h (   D   O   H )   D  o  n  a  t  e  L  i  f  e    ™   R  e  g i  s  t  r  y  o  n l i  n  e

  a  t    w    w    w .  n  y  h  e  a l  t  h .  g  o  v  o  r  p  r  o  v i  d  e  y  o  u  r  n  a   m  e  a  n  d  a  d  d  r  e  s  s  b  e l  o   w .

   Y  o  u   w i l l  r  e  c  e i  v  e  a  c  o  n  fi  r   m  a  t i  o  n l  e  t  t  e  r  f  r  o   m   D   O   H ,   w  h i  c  h   w i l l  a l  s  o

  p  r  o  v i  d  e  y  o  u  a  n  o  p  p  o  r  t  u  n i  t  y  t  o l i   m i  t  y  o  u  r  d  o  n  a  t i  o  n .

   B  y  s i  g  n i  n  g   b  e l  o    w ,  y  o  u  c  e  r  t i  f  y  t  h  a  t  y  o  u  a  r  e :

      • 

      • 

  t i  s  s  u  e  s  f  o  r  t  r  a  n  s  p l  a  n  t  a  t i  o  n ,  r  e  s  e  a  r  c  h ,  o  r  b  o  t  h ;

      •a  u  t  h  o  r i  z i  n  g  t  h  e   B  o  a  r  d  o  f  E l  e  c  t i  o  n  s  t  o  p  r  o  v i  d  e

  y  o  u  r  n  a   m  e  a  n  d i  d  e  n  t i  f  y i  n  g i  n  f  o  r   m  a  t i  o  n  t  o

   D   O   H  f  o  r  e  n  r  o l l   m  e  n  t i  n  t  h  e   R  e  g i  s  t  r  y ;

      • 

  f  o  r   m  a  t i  o  n  t  o  f  e  d  e  r  a l l  y  r  e  g  u l  a  t  e  d  o  r  g  a  n  p  r  o  c  u  r  e -

   m  e  n  t  o  r  g  a  n i  z  a  t i  o  n  s  a  n  d   N   Y  S - l i  c  e  n  s  e  d  t i  s  s  u  e

  a  n  d  e  y  e  b  a  n  k  s  a  n  d  h  o  s  p i  t  a l  s  u  p  o  n  y  o  u  r  d  e  a  t  h .

 (   O  p  t i  o  n  a l )   R  e  g i  s  t  e  r  t  o  d  o  n  a  t  e  y  o  u  r  o  r  g  a  n  s  a  n  d  t i  s  s  u  e  s

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   A  d  d  r  e  s  s

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   H  e i  g  h  t  F  t . I  n .

    S  i    g    n     D   a   t   e

   S  u  f  fi  x

   A   p  t .   N  u    m   b  e  r

    M i  d  d l  e I  n i  t i  a l

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   B i  r  t  h  d  a  t  e   Y   Y   Y   Y D   D   /  /    M   M

 Board of Elections Borough Ofces

General Ofce

32 Broadway, 7 Fl

New York, NY 10004-1609

Tel: 1.212.487.5300

Staten Island1 Edgewater Plaza, 4 FlStaten Island, NY 10305Tel: 1.718.876.0079

Manhattan200 Varick St., 10 FlNew York, NY 10014Tel: 1.212.886.2100

Bronx1780 Grand Concourse, 5 FlBronx, NY 10457Tel: 1.718.299.9017

Brooklyn345 Adams Street, 4 FlBrooklyn, NY 11201Tel: 1.718.797.8800

Queens126-06 Queens BoulevardKew Gardens, NY 11415Tel: 1.718.730.6730

Borough Ofces

  E  n  g l i  s  h  6  /  1  1

  1  8  y  e  a  r  s  o  f  a  g  e  o  r  o l  d  e  r ;

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  a  n  d  a  u  t  h  o  r i  z i  n  g   D   O   H  t  o  a l l  o   w  a  c  c  e  s  s  t  o  t  h i  s i  n -

   B   O   A   R   D   O   F   E  L   E   C   T I   O   N   S

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   N   O   P   O   S   T   A   G   E

   N   E   C   E   S   S   A   R   Y

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