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Kansas Voter Registration Application

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Kansas Voter Registration Application
Kansas Voter Registration Application
Kansas Voter Registration Instructions
For further information, contact the Ofce of the Secretary of State,
1-800-262-VOTE (8683) V/TTY. This form is available at www.sos.ks.gov.
You can use this application to:
register to vote in Kansas
change your name, address, or afliation with a political party
To register to vote, you must:
be a U.S. citizen and a resident of the state of Kansas.
have reached the age of 18 years before the next election.
have received nal discharge from imprisonment, parole, or condi-
tional release if convicted of a felony.
have abandoned your former residence and/or name.
How to register to vote:
Return your completed application to your county. Addresses are on
the back of this application. Your county election ofcer will mail you a
notice when your application has been processed.
Voter registration closes 21 days before any election. In order to be
eligible to vote in that election, your application must be postmarked
on or before that date.
If you decline to register to vote, that fact will remain condential and
will be used for voter registration purposes only. If you do register to
vote, the ofce where you apply will be kept condential and will be
used for voter registration purposes only.
If this form is incomplete, it may be rejected.
Identication number requirements
Enter your current Kansas driver’s license number or nondriver’s identica-
tion card number. If you do not have either one, enter the last four digits
of your Social Security number. If you do not have any of these numbers,
write “none” in the box. The number will be used for administrative pur-
poses only and will not be disclosed to the public. K.S.A. 25-2309
Proof of U.S. citizenship
If you are registering for the rst time in Kansas, you must submit
proof of United States citizenship. You may provide a copy on paper or
electronically, or you may show the document to an election ofcer or
ofcial registrar. The following is a partial list of acceptable documents:
Birth certicate that veries U.S. citizenship
U.S. passport (may be expired)
U.S. naturalization documents or the number of the certicate of
naturalization
Bureau of Indian Affairs card number, tribal treaty number or tribal
enrollment number
U.S. hospital record of birth indicating place of birth in the U.S.
U.S. military record of service showing the applicant’s name and U.S.
birthplace
For a list of acceptable documents, visit http://www.gotvoterid.com. If you do not have any
of the documents, you may appeal to the state election board.
Rev. 12/12/12 tc
Kansas Voter Registration Application
Warning: If you submit a false voter registration application,
you may be convicted and sentenced to up to 17 months in prison.
Qualications: If you mark “no” in response to either Question 1 or 2, do not complete this form.
1. Are you a citizen of the United States of America
Yes
No
2. Will you be 18 years of age on or before Election Day
Yes
No
Last Name (please print) First Name Middle Jr. Sr. II III
Male
Female
Residential Address (include apt. or space number) City County Zip
Mailing Address (if different than residential address) City Zip Date Residence Established (MM/DD/YY)
Birth Date (MM/DD/YY) Daytime Phone Number (if available) Naturalization Number (if applicable) Driver’s License Number or Last 4 Social Security (see instructions)
Party Afliation: Choose one of the following:
Democratic
Republican
Libertarian
Not afliated with a party
Complete if previously
registered (please print)
Previous Name Previous Residential Address (Street, City, State, Zip, County)
Signature: I swear or afrm that I am a citizen of the United States and a Kansas resident, that I will be 18 years old before the next election, that if convicted of a felony, I
have had my civil rights restored, that I have abandoned my former residence and/or other name, and that I have told the truth on this application.
Signature Date (MM/DD/YY)
For ofce use only: Ward ______________________ Pct. ______________________ School Dist. ______________________ Member Dist. ______________________
Sen. ________________ Rep. ________________ CoComm ________________ Section ________________ Township ________________ Range _________________
Print in blue or black ink, fold on the center line, seal, and return.
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Kansas Voter Registration Application
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