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State of Alaska Voter Registration Application

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State of Alaska Voter Registration Application
State of Alaska Voter Registration Application
C03 (Rev. 02/01/2011)
STATE OF ALASKA VOTER REGISTRATION APPLICATION
Refer to instructions on the reverse side for specific information and identification requirements.
Please print clearly in blue or black ink.
1.
You MUST complete this section for registration.
Yes
Yes
No
No
I am a citizen of the United States.
I am at least 18 years old or will be within 90 days of completing this application.
If you checked NO to either question, do not complete this form as you are not eligible to register to vote.
2.
Last Name First Name Middle Initial Suffix (Sr., Jr., etc.)
3.
Former Name: (If your name has changed)
4.
You MUST provide the Alaska residence address where you claim residency. Do not use PO, PSC, HC or RR.
House # Street Name Apt #
City
ALASKA
State
* Keep my residence address confidential. (Your mailing address in section 5 must be DIFFERENT from your residence
address in section 4 to remain confidential.)
5.
Mailing Address:
10.
I am a voter with a disability and would like
information on alternative voting methods.
11.
I am interested in serving as an election official.
(Provide your phone number and/or email address in section 12.)
12.
Daytime Phone No.
Evening Phone No.
Email Address
13.
Political Affiliation For information on political
types see reverse No. 5.
Select only ONE Below
Political Parties:
Alaska Democratic Party
Alaska Libertarian Party
Alaska Republican Party
Alaskan Independence Party
or Political Groups:
Green Party of Alaska
Alaska Constitution Party
Veterans Party of Alaska
or Other:
Nonpartisan (no party affiliation)
Undeclared (no party declared)
_________________________________
6.
You MUST provide at least ONE
*Social Security No.
*Last 4 Digits of Social Security No.
*Alaska Driver’s License No.
*Alaska State ID Card No.
I have not been issued a Social Security, Alaska
Driver’s License or State ID number.
7.
You MUST provide
*Date of Birth
Month Day Year
8. *AK Voter Number
(If known)
9.
Sex
Male Female
14.
If you are registered to vote in another state, you MUST cancel that registration by providing the following:
City: State: County: Zip Code:
Voter Certificate. Read and Sign: I certify, under penalty of perjury, that the above information I provided on this document is true
and correct. I am not registered to vote in another state, or I have provided information to cancel that registration. I further certify that
I am a resident of Alaska and I have not been convicted of a felony, or having been so convicted, have been unconditionally discharged
from incarceration, probation and/or parole.
WARNING: If you provide false information on this application you can be convicted of a misdemeanor AS 15.56.050.
*SIGNATURE: DATE:
Registrar/Agency/Official – Check ID and complete this section
For Office Use Only
VN
D/P
Registrar Name Voter # or SSN
OR
Agency Name
*Items are kept confidential by the Division of Elections and are not available for public inspection except that confidential addresses may
be released to government agencies or during election processes as set out in state law.
State of Alaska Voter Registration Application
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