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North Carolina Voter Registration Application

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North Carolina Voter Registration Application
North Carolina Voter Registration Application
version102013
06w
NORTH CAROLINA VOTER REGISTRATION APPLICATION
Please use black ink and print legibly.
1
Are you a citizen of the United States of America
Yes
No
Will you be at least 18 years of age on or before election day
IF YOU CHECKED "NO" IN RESPONSE TO THIS QUESTION,
DO NOT SUBMIT THIS FORM.
IF YOU CHECKED "NO" IN RESPONSE TO THIS QUESTION,
DO NOT SUBMIT THIS FORM.
2
Last Name (Required)
First Name (Required)
Middle Name (Required)
Jr Sr II
III IV V
3
Date of Birth MMDDYYYY (Required) State of Birth/Country of Birth
If you know your NC Voter Registration Number, enter it below.
If you have a NC drivers license or non-operators ID card, enter the number below.
Enter the last 4 digits of your SSN.
Check here if you do not have a NC
drivers license, ID card, or a SSN.
RESIDENTIAL ADDRESS INFORMATION - No P.O. Boxes or Rural Routes
4
Street Address where you live (Required) Apartment, Lot, or Unit Number
City (Required)
State
Zip Code
County
Have you lived here
for 30 days or more
Yes No
If "No," date moved MMDDYYYY
Phone (Optional)
MAP/DIAGRAM
If you do not have a street address, draw a map of where you reside.
Please include roads and landmarks.
N C
MAILING ADDRESS
5
Mailing Address (If different from your residential address)
Mailing Address Line 2
City State Zip Code
6
GENDER RACE ETHNICITY POLITICAL PARTY AFFILIATION
Female
Male
African American/
Black
Asian
White
American Indian/
Alaska Native
Multiracial
Other
Hispanic/Latino
Not Hispanic/ Latino
Democrat Republican
Libertarian
Unaffiliated Other
If you indicate a political party that is not currently qualified, or
you do not indicate a choice, you will be listed as "Unaffiliated."
PREVIOUS VOTER REGISTRATION (This information will be used to cancel your previous voter registration in another county or state.)
7
Last Name used in Previous Registration First Name used in Previous Registration
Previous Address Previous County
Previous City Previous State Previous Zip Code
I attest, under penalty of perjury, that in addition to having read and understood the contents of this form, that:
· I am a United States citizen, as indicated above;
· I am at least 18 years of age, or will be by the date of the general election;
· I shall have been a resident of North Carolina, this county, and precinct for 30 days before the election in which I intend to vote;
· I will not vote in any other county or state after submission of this form and if I am registered elsewhere, I am canceling that registration at this time; and
· I have not been convicted of a felony, or if I have been convicted of a felony, I have completed my sentence, including any probation or parole.
(Citizenship and voting rights are automatically restored upon completion of the sentence. No special document is needed.)
Signature (Required) Date
X
Fraudulently or falsely completing this
form is a Class I Felony under Chapter
163 of the NC General Statutes.
Yes
No
North Carolina Voter Registration Application
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