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Arkansas Voter Registration Form

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Arkansas Voter Registration Form
Arkansas Voter Registration Form
Please complete the sections below if:
You were previously registered in another county or state, or
You wish to change the name or address on your current registration.
ARKANSAS VOTER REGISTRATION APPLICATION
C
heck all that apply:
_
___ This is a new registration.
____ This is a name change.
____ This is an address change.
____ This is a party change.
1
M
r.
M
rs.
Miss
M
s.
L
ast Name
J
r. Sr.
I
I. III. IV.
F
irst Name
M
iddle Name
2
A
pt. or Lot #
C
ity/Town
S
tate
PLEASE PRINT AND USE BLACK INK TO COMPLETE
3
4
Date of Birth
_________
/
_________
/
_________
Month Day Year
5
(A) Are you a citizen of the United States of America and an Arkansas resident
Yes No
(B) Will you be eighteen (18) years of age or older on or before election day
Yes No
(
C)
A
re you presently adjudged mentally incompetent by a court of competent jurisdiction
Yes No
(
D)
H
ave you ever been convicted of a felony without
y
our sentence having been
discharged or pardoned
Yes No
If you checked No in response to either questions A or B, do not complete this form.
If you checked Yes in response to either questions C or D, do not complete this form.
A
Mr.
Mrs.
Miss
Ms.
First Name
Middle Name(s)
B
Previous House Number and Street Name
Apt.or Lot #
City or Town
State
C
Write in the names of the crossroads (or streets) nearest where you live.
Draw an “X” to show where you live.
Use a dot to show any schools, churches, stores or other landmarks near
where you live and write the name of the landmark.
Public School
X
Grocery
Store
Woodchuck Road
Route #2
Rev. 6/11
NORTH
Office Use Only
A
ddress Where You Live (See Section “C” Below)
(Rural addresses must draw map.)
Z
ip Code
A
ddress Where You Receive Mail If Different From Above
C
ity/Town
S
tate
Z
ip Code
Home & Work Phone Numbers (Optional)
(
H) (W)
ID Number - Check the applicable box and provide the appropriate number.
Arkansas D
riverʼs license number
_
___________________________________
I
f you do not have a driverʼs license provide the last 4 digits of social
security number _____________________________
I have neither a driverʼs license nor social security number.
9
Date:
_____________
/
_____________
/
_____________
M
onth Day Year
H
ave you ever voted in a federal election in this State
Yes No
If applicant is unable to sign his/her name, provide name, address and
phone number of the person providing assistance:
Name ________________________ Address: ________________________
City:___________________ State:_____ Phone#:_____________________
8
MAIL REGISTRANTS: PLEASE SEE SECTION D.
Zip Code
If you live in a rural area but do not have a house or street number, or if
you have no address, please show on the map where you live.
Example
D
IDENTIFICATION REQUIREMENTS
IMPORTANT: If your voter registration application
form is submitted by mail and you are registering for
the first time, and you do not have a valid Arkansas
driver's license number or social security
number
,
in order to avoid the additional identification
requirements upon voting for the first time you
must submit with the mailed registration form: (a) a
current
and valid photo identification; or (b) a copy
of a current utility bill, bank statement, government
check, paycheck, or other government document
that shows your name and address.
Apt. or Lot #
C
ounty
C
ounty
6
P
arty Affiliation (Optional)
T
he information I have provided is true to the best of my knowledge. I do not claim the right
to vote in another county or state. If I have provided false information, I may be subject to
a fine of up to $10,000 and/or imprisonment of up to 10 years under state and federal laws.
11
Signature of elector - Please sign full name or put mark.
10
Jr. Sr.
II. III. IV.
A
ssigned ID
Date of Birth
_________
/
_________
/
_________
Month Day Year
Agency Code (For Official Use Only)
Previous Last Name
7
E
-mail Address
(
Optional)
Arkansas Voter Registration Form
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