NJ Division of Elections - 02/16/16
New Jersey
Voter Registration Application
Need More Information? Check boxes below if you would like to receive more information about:
o
voting by mail
o
polling place accessibility
o
available election materials in
o
becoming a poll worker
o
voting if you have a disability,
this alternative language:
including visual impairment
For further information visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837)
Important Instructions for sections 5, 6 and 10
5 eistrants who are submittin this form by mail and are reisterin to vote for the 昀rst time: If you do not have any of the information
reuired by section 5, or the information you provide cannot be veri昀ed, you will be ased to provide a CO of a current and valid
photo ID, or a document with your name and current address on it to avoid havin to provide identi昀cation at the pollin place.
Note: ID Numbers are Con昀dential and will not be released by any governmental agency. Any person who uses such numbers
illegally shall be subject to criminal penalties.
If you are homeless, you may complete section by providin a contact point or the location where you spend most of your time.
10 ou may declare a political party af昀liation or you may declare to be unaf昀liated, reardless of any prior party af昀liation. If you are a
previously af昀liated voter who wants to chane political party af昀liation or become unaf昀liated, you must 昀le this form no later than
55 days before the primary election in order to vote in the primary election. Completin section 10 is OTIONL and will not affect
the acceptance of your voter reistration application.
Chec boxes
o
New Registration
o
ddress Chane
o
olitical arty f昀liation
that apply:
o
Name Chane
o
Sinature pdate or Non-af昀liation Chane
Do you wish to declare a political party af昀liation
o
es, the party name is
.
(Optional)
o
No, I do not wish to be af昀liated with any political party.
If you DO NOT have a NJ Driver’s License or MVC Non-Driver
ID, provide the last 4 digits of your Social Security Number.
Are you a U.S. Citizen? o Yes o No
(If No, DO NOT complete this form)
Date of Birth
NJ Driver’s License Number or MVC Non-driver ID Number
Last Name
First Name
Middle Name or Initial
Suf昀x
(Jr., Sr., III)
Home Address (DO NOT use PO Box)
Apt.
Municipality
County Zip Code
Are you at least 17 years of age? o Yes o No
(If No, DO NOT complete this form)
Mailing Address if different from above
Last Address Registered to Vote (DO NOT use PO Box)
Former Name if Making Name Change
b. E-Mail Address (Optional)
Gender
o
Female
o
Male
Apt.
Municipality
County
Zip Code
Apt.
Municipality
County
Zip Code
8
10
2
3
4
5
6
7
Signature: Sign or mark and date on lines below
11
9
If applicant is unable to complete this form, print the
name and address of individual who completed this form.
Name
Date
Address
Clerk
Registration #
Of昀ce Time Stamp
o by mail
o in person
o
“I swear or af昀rm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”
Declaration - I swear or af昀rm that:
l
I am a U.S. Citizen
l I live at the above address
l I am at least 17 years old, and under-
stand that I may not vote until reaching
the age of 18.
FOR OFFICIAL
USE ONLY
1
Date
State
State
State
Please print clearly in ink. All information is required unless marked optional.
a. Day Phone Number (Optional)
X
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __
l I will have resided in the State and county
at least 30 days before the next election
l I am not on parole, probation or serving a
sentence due to a conviction for an indictable
offense under any federal or state laws
l I understand that any false or
fraudulent registration may subject
me to a 昀ne of up to $15,000,
imprisonment up to 5 years, or
both pursuant to R.S. 19:34-1
33