Pennsylvania Voter Registration Application Form General Instructions 1. Please provide all information on the application as required. Read all instructions carefully before you fill out the application. 2. If you are currently registered, you do not need to re-register unless you have moved or changed your name since you last registered to vote. 3. In order to vote at the next election, this application must be received by your county voter registration office 30 days before the election, or postmarked no later than the thirtieth day before the election. Military electors may apply at any time. 4. Print out, fill in completely, sign and date the form. Place completed application in an envelope addressed to your local county voter registration office (addresses are available on the web at www.dos.state.pa.us ) and affix the proper postage. 5. You are not registered to vote until your application has been processed and accepted by the county voter registration office. If accepted, the county voter registration office will send you, via nonforwardable mail, a Voter Identification Card. If you do not receive a Voter Identification Card within 14 days of the date you submit this application, contact your county voter registration office. 6. If you decline to register to vote, your decision will remain confidential. If you register to vote, the office at which you register will remain confidential. IDENTIFICATION WHEN YOU VOTE Pennsylvania law requires that registered voters who appear to vote for the first time in an election district after December 9, 2003 must present a form of identification. If this is the first election in which you are voting in your election district, and you intend to vote by absentee ballot in an election after January 1, 2004, you may include a form of identification with this voter registration application form rather than include it with your application for an absentee ballot. A list of the acceptable forms of identification may be obtained from your county voter registration office or from the Pennsylvania Department of State at its website, www.dos.state.pa.us INSTRUCTIONS FOR FILLING OUT THIS FORM (PLEASE READ CAREFULLY) Box 1. Citizenship and Age: If the answer to either question is “No,” do not complete this form because you are not eligible to register to vote. Box 2. Application Type: Please check the appropriate box. If you are a Federal or State employee and wish to retain your voting residence in the county where you last resided, please check the appropriate box. Box 3. Name, Driver’s License and Social Security Number: Print your last name, first name and middle name or initial. Circle Jr., Sr., II, III, IV if applicable. You must supply a Driver’s License Number if you have one. If you do not have a Driver’s License Number, you must supply the last four digits of your Social Security Number. If you do not have a Social Security Number, please write None in the boxes. Box 4: 4a. Address of Residence: Fill in your complete address of residence. P.O. boxes may not be used here unless there is no physical address. Print street address, city and zip code. (If the residence is only a portion of the house, include the location or number of the room, apartment or floor, which is occupied.) In Box 4b include your telephone number (Optional). In Box 4c fill in the name of the municipality (city, borough or township) and county where you live. Use the map in the box below if you cannot otherwise identify your address. If your address of residence listed in Box 4a has no street number or street name (for example, Schoolhouse Road or RR2 Box 3) use the box above to draw a map of where you live. Include landmarks and roads. Box 5. Mailing Address: Fill in your mailing address, if different from Box 4a. Box 6. Date of Birth: Fill in the month, day and year of your birth. Box 7. Race: Fill in your race (Optional). Box 8. Prior Registration: If you were registered before, fill in the name used on previous registration in Box 8a and address, county and year of previous registration in Box 8b. Box 9. Political Party: Check block for political party or no affiliation. You must register with a party if you want to take part in that party’s primary. Box 10. If you were assigned a Voter Identification Number, which appears on your Voter Identification Card, place that Identification Number here. If you are applying to register to vote for the first time, leave this box blank. Box 11. Registration Declaration: You must be a citizen of the United States to register to vote in the Commonwealth of Pennsylvania. Please read the registration declaration carefully. Please sign and print your name and date the application. PENALTY FOR FALSIFYING REGISTRATION DECLARATION. WARNING : If a person signs an official registration application knowing a statement declared in the application to be false, makes a false registration, or furnishes false information, the person commits perjury. Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven years, or a fine not exceeding $15,000, or both, at the discretion of the court. Submitting an application containing false information may also subject a person to other penalties, including loss of the right of suffrage, under state or federal law. Box 12. Name of Assistant: If the applicant is unable to sign the application, the person who assisted the applicant must provide his or her name, address and telephone number.
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Pennsylvania Voter Registration Application Form General Instructions
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Pennsylvania Voter Registration Application Form General Instructions
1. Please provide all information on the application as required. Read all instructions carefully before you fill out the application. 2. If you are currently registered, you do not need to re-register unless you have moved or changed your name since you last
registered to vote. 3. In order to vote at the next election, this application must be received by your county voter registration office 30 days before the
election, or postmarked no later than the thirtieth day before the election. Military electors may apply at any time. 4. Print out, fill in completely, sign and date the form. Place completed application in an envelope addressed to your local county
voter registration office (addresses are available on the web at www.dos.state.pa.us) and affix the proper postage. 5. You are not registered to vote until your application has been processed and accepted by the county voter registration office. If
accepted, the county voter registration office will send you, via nonforwardable mail, a Voter Identification Card. If you do not receive a Voter Identification Card within 14 days of the date you submit this application, contact your county voter registration office.
6. If you decline to register to vote, your decision will remain confidential. If you register to vote, the office at which you register will remain confidential.
IDENTIFICATION WHEN YOU VOTE Pennsylvania law requires that registered voters who appear to vote for the first time in an election district after December 9, 2003 must present a form of identification. If this is the first election in which you are voting in your election district, and you intend to vote by absentee ballot in an election after January 1, 2004, you may include a form of identification with this voter registration application form rather than include it with your application for an absentee ballot. A list of the acceptable forms of identification may be obtained from your county voter registration office or from the Pennsylvania Department of State at its website, www.dos.state.pa.us
INSTRUCTIONS FOR FILLING OUT THIS FORM (PLEASE READ CAREFULLY) Box 1. Citizenship and Age: If the answer to either question is “No,” do not complete this form because you are not eligible to register to vote. Box 2. Application Type: Please check the appropriate box. If you are a Federal or State employee and wish to retain your voting residence in the county where you last resided, please check the appropriate box. Box 3. Name, Driver’s License and Social Security Number: Print your last name, first name and middle name or initial. Circle Jr., Sr., II, III, IV if applicable. You must supply a Driver’s License Number if you have one. If you do not have a Driver’s License Number, you must supply the last four digits of your Social Security Number. If you do not have a Social Security Number, please write None in the boxes. Box 4: 4a. Address of Residence: Fill in your complete address of residence. P.O. boxes may not be used here unless there is no physical address. Print street address, city and zip code. (If the residence is only a portion of the house, include the location or number of the room, apartment or floor, which is occupied.) In Box 4b include your telephone number (Optional). In Box 4c fill in the name of the municipality (city, borough or township) and county where you live. Use the map in the box below if you cannot otherwise identify your address.
If your address of residence listed in Box 4a has no street number or street name (for example, Schoolhouse Road or RR2 Box 3) use the box above to draw a map of where you live. Include landmarks and roads.
Box 5. Mailing Address: Fill in your mailing address, if different from Box 4a. Box 6. Date of Birth: Fill in the month, day and year of your birth. Box 7. Race: Fill in your race (Optional). Box 8. Prior Registration: If you were registered before, fill in the name used on previous registration in Box 8a and address, county and year of previous registration in Box 8b. Box 9. Political Party: Check block for political party or no affiliation. You must register with a party if you want to take part in that party’s primary. Box 10. If you were assigned a Voter Identification Number, which appears on your Voter Identification Card, place that Identification Number here. If you are applying to register to vote for the first time, leave this box blank. Box 11. Registration Declaration: You must be a citizen of the United States to register to vote in the Commonwealth of Pennsylvania. Please read the registration declaration carefully. Please sign and print your name and date the application. PENALTY FOR FALSIFYING REGISTRATION DECLARATION. WARNING: If a person signs an official registration application knowing a statement declared in the application to be false, makes a false registration, or furnishes false information, the person commits perjury. Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven years, or a fine not exceeding $15,000, or both, at the discretion of the court. Submitting an application containing false information may also subject a person to other penalties, including loss of the right of suffrage, under state or federal law.
Box 12. Name of Assistant: If the applicant is unable to sign the application, the person who assisted the applicant must provide his or her name, address and telephone number.
ADDRESSES OF COUNTY VOTER REGISTRATION OFFICESTo mail this application, write the address of the County Voter Registration Office in the proper area on the reverse side of this form.
If your address of residence listed in Box 4a has no street number or streetname (for example, Schoolhouse Road or RR2 Box 3) use the box aboveto draw a map of where you live. Include landmarks and roads.
ADAMS COUNTY111-117 BALTIMORE ST 1ST FLGETTYSBURG PA 17325-2312(717) 337-9832
ALLEGHENY COUNTY542 FORBES AVE STE 604PITTSBURGH PA 15219-2953(412) 350-4500
ARMSTRONG COUNTYADMIN/BLDG 500 E MARKET STKITTANNING PA 16201(724) 548-3222
BEAVER COUNTY810 THIRD STBEAVER PA 15009-2145(724) 728-3934 EXT 11298
BEDFORD COUNTY211 S JULIANA ST PO BOX 166BEDFORD PA 15522-0166(814) 623-4807
BERKS COUNTY633 COURT STREADING PA 19601-3540(610) 478-6490
BLAIR COUNTY423 ALLEGHENY ST STE 043HOLLIDAYSBURG PA 16648-2022(814) 693-3150
BRADFORD COUNTY301 MAIN STTOWANDA PA 18848-1878(570) 265-1717
BUCKS COUNTY55 E COURT STDOYLESTOWN PA 18901-4318(215) 348-6163
BUTLER COUNTYPO BOX 1208BUTLER PA 16003-1208(724) 284-5308
CAMBRIA COUNTY200 S. CENTER STEBENSBURG PA 15931(814) 472-5440
CAMERON COUNTY20 E FIFTH STEMPORIUM PA 15834-1469(814) 486-2315
CARBON COUNTYBROADWAY & HAZARD SQ PO BOX 129JIM THORPE PA 18229-0129(570) 325-4801
CENTRE COUNTY420 HOLMES STBELLEFONTE PA 16823-1488(814) 355-6703
CHESTER COUNTY601 WESTTOWN RD PO BOX 2747WEST CHESTER PA 19380-0990(610) 344-6410
CLARION COUNTY421 MAIN STCLARION PA 16214-1093(814) 226-4000 EXT 2205
CLEARFIELD COUNTY230 E MARKET ST STE 108CLEARFIELD PA 16830(814) 765-2641 EXT 5996
CLINTON COUNTY232 E MAIN ST GARDEN BLDG 3RD FLLOCK HAVEN PA 17745-1385(570) 893-4019
COLUMBIA COUNTY35 W MAIN ST PO BOX 380BLOOMSBURG PA 17815-0380(570) 389-5640
CRAWFORD COUNTY903 DIAMOND PARKMEADVILLE PA 16335-2678(814) 333-7306
CUMBERLAND COUNTY37 E HIGH ST STE 104CARLISLE PA 17013-3044(717) 240-6385
DAUPHIN COUNTYPO BOX 1295HARRISBURG PA 17108-1295(717) 255-2793
DELAWARE COUNTYGOV'T CENTER BLDG 201 W FRONT STMEDIA PA 19063-2728(610) 891-4659
ELK COUNTY300 CENTER ST PO BOX 448RIDGWAY PA 15853(814) 776-5337
ERIE COUNTY140 W 6TH ST RM 105ERIE PA 16501-1096(814) 451-6275
FAYETTE COUNTY22 E MAIN ST PUBLIC SERVICE BLDGUNIONTOWN PA 15401(724) 430-1289
FOREST COUNTYPO BOX 126TIONESTA PA 16353-0126(814) 755-3537
FRANKLIN COUNTY157 LINCOLN WAY EASTCHAMBERSBURG PA 17201-2211(717) 261-3886
FULTON COUNTY116 W MARKET ST STE 203MCCONNELLSBURG PA 17233(717) 485-3691
GREENE COUNTY93 E HIGH ST RM 102WAYNESBURG PA 15370(724) 852-5230
HUNTINGDON COUNTY223 PENN ST COURTHOUSEHUNTINGDON PA 16652-1486(814) 643-3091
INDIANA COUNTY825 PHILADELPHIA STINDIANA PA 15701-3934(724) 465-3852
JEFFERSON COUNTY155 MAIN ST JEFFERSON PLACEBROOKVILLE PA 15825-1269(814) 849-1605
JUNIATA COUNTYBRIDGE ST PO BOX 68MIFFLINTOWN PA 17059-0068(717) 436-7706
LACKAWANNA COUNTY135 JEFFERSON AVE SUITE 100SCRANTON PA 18503(570) 963-6737
LANCASTER COUNTYPO BOX 83480LANCASTER PA 17608-3480(717) 299-8293
LAWRENCE COUNTY430 COURT STNEW CASTLE PA 16101-3593(724) 656-2161
LEBANON COUNTY400 S EIGHTH STLEBANON PA 17042-6794(717) 274-2801 EXT 2243
LEHIGH COUNTY17 S 7TH STALLENTOWN PA 18101-2400(610) 782-3194
LUZERNE COUNTY200 N RIVER STWILKES-BARRE PA 18711(570) 825-1715
LYCOMING COUNTY48 W THIRD STWILLIAMSPORT PA 17701-0536(570) 327-2267
MCKEAN COUNTYPO BOX 1507SMETHPORT PA 16749-0507(814) 887-3203
MERCER COUNTY#5 COURTHOUSEMERCER PA 16137-1227(724) 662-3800 EXT 2240
MIFFLIN COUNTY20 N WAYNE STLEWISTOWN PA 17044(717) 248-6571
MONROE COUNTYONE QUAKER PLAZA RM 105STROUDSBURG PA 18360-2170(570) 517-3165
MONTGOMERY COUNTYCOURTHOUSE PO BOX 311NORRISTOWN PA 19404-0311(610) 278-3280
MONTOUR COUNTY29 MILL STDANVILLE PA 17821(570) 271-3000
NORTHAMPTON COUNTYWOLF BLDG 45 N SECOND STEASTON PA 18042-3695(610) 559-3055
NORTHUMBERLAND COUNTY609 MARKET STSUNBURY PA 17801-2360(570) 988-4208
PERRY COUNTYPO BOX 37NEW BLOOMFIELD PA 17068-0037(717) 582-2131 EXT 4110
PHILADELPHIA COUNTY520 N DELAWARE AVE 5TH FLPHILADELPHIA PA 19123-4295(215) 686-1505
PIKE COUNTY506 BROAD STMILFORD PA 18337-1535(570) 296-3426
POTTER COUNTY1 E SECOND ST RM 22ACOUDERSPORT PA 16915-1690(814) 274-8467
SCHUYLKILL COUNTY114 S CLAUDE A LORD BLVDPOTTSVILLE PA 17901-3602(570) 622-3040
SNYDER COUNTYPO BOX 217MIDDLEBURG PA 17842-0217(570) 837-4209
SOMERSET COUNTY300 N CENTER AVE STE 510SOMERSET PA 15501(814) 445-1549
SULLIVAN COUNTYPO BOX 157LAPORTE PA 18626-0157(570) 946-5201
SUSQUEHANNA COUNTYPO BOX 218 MAPLE STMONTROSE PA 18801-0218(570) 278-4600 EXT 220
TIOGA COUNTYPO BOX 589 118 MAIN STWELLSBORO PA 16901-0589(570) 723-8230
UNION COUNTY103 S SECOND STLEWISBURG PA 17837-1996(570) 524-8681
VENANGO COUNTY1174 ELK ST PO BOX 831FRANKLIN PA 16323-0831(814) 432-9514
WARREN COUNTY204 FOURTH AVEWARREN PA 16365-2399(814) 728-3401
WASHINGTON COUNTY100 W BEAU ST RM 206WASHINGTON PA 15301(724) 228-6750
WAYNE COUNTY925 COURT STHONESDALE PA 18431-1996(570) 253-5978
WESTMORELAND COUNTY2 N MAIN ST STE 109GREENSBURG PA 15601(724) 830-3150
WYOMING COUNTY1 COURTHOUSE SQTUNKHANNOCK PA 18657-1216(570) 996-2226
YORK COUNTY1 WEST MARKETWAYYORK PA 17401-1256(717) 771-9604
For a listing of availablecounty e-mail addresses, go to:www.dos.state.pa.usIf you are interested in becom-ing a poll worker, contact yourcounty voter registration office.
INSTRUCTIONS FOR FILLING OUT THIS FORM (PLEASE READ CAREFULLY)
Rule, Weight=0.5 ptScreen=10%, 150 line
1
6 7 8 9
12
Telephone Number (Optional)Address of residence, include street and city (Use map above if no street number or name) (If only P.O. box, see above)
Name on previous registration In which party do you wish to register?
DemocraticRepublicanLibertarianGreen
No affiliationOther (Please specify):
NAME CITY, BORO, OR TWP. WARD DISTRICT
SE
AL H
ER
ED
O N
OT R
EM
OV
E S
EA
L H
ER
ED
O N
OT
RE
MO
VE
OFF
ICIA
LU
SE
ON
LY
OFFIC
IAL
US
E O
NLY
X
FOLDFOLD
Place signature with full name (or mark) below.(Please see Penalty for Falsifying Declaration.)
Date of Birth Race (Optional)
Print Your Name Below
Address
Year of previous registrationAddress of previous registration
Date
8b
County of previous registrationa
PENNSYLVANIA VOTER REGISTRATION APPLICATION
DO NOT WRITE IN SHADED AREAS
Apt #
COUNTY VOTER I.D.#
Name of person who assisted in the completion of this application
AND I HEREBY AFFIRM THAT the information I have provided in this registrationdeclaration is true. I understand that this registration declaration will be acceptedfor all purposes as the equivalent of an affidavit; and if the registration contains amaterially false statement, I will be subject to penalties for perjury.
11
10
Telephone No.
NORTH
EASTWEST
SOUTH
WARNING: If a person signs an official registration application knowing astatement declared in the application to be false, makes a false registration, orfurnishes false information, the person commits perjury. Perjury is punishable,upon conviction, by a term of imprisonment not exceeding seven years, or a finenot exceeding $15,000, or both, at the discretion of the court. Submitting anapplication containing false information may also subject a person to otherpenalties, including loss of the right of suffrage, under state or federal law.
PENALTY FOR FALSIFYING REGISTRATION DECLARATION
Mailing Address: Fill in mailing address, if different from Box 4a.Date of Birth: Fill in month, day and year of your birth.Race: Fill in your race. (Optional)
Prior Registration: If you were registered before, fill in name of previousregistration in Box 8a and address, county and year of previous registra-tion in Box 8b.Political Party: Check block for political party or no affiliation. You mustregister with a party if you want to take part in that party's primary.
If you were assigned a Voter Identification Number, which appears onyour Voter Identification Card, place that Identification Number here. Ifyou are applying to register to vote for the first time leave this box blank.
Registration Declaration: 11a You must be a citizen of the United Statesto register to vote in the Commonwealth of Pennsylvania.11b Please readthe registration declaration carefully. Please sign and print your name anddate the application.
Zip Code 4b
Zip CodeStateCityMailing address (if different than address of residence)County where you liveMunicipality where you live 54c
4a
State
Middle Name/InitialFirst NameLast Name32 New Registration Change of Name Change of Address Change of Party
Are you a citizen of the United States of America?Will you be 18 years of age on or before election day?
Yes No Yes No }
Citizenship and Age: If the answer to either question is "No," do notcomplete this form because you are not eligible to register to vote.Application Type: Please check the appropriate box. If you are a Federalor State employee and wish to retain your voting residence in the countywhere you last resided, please check the appropriate box. Name, Driver's License and Social Security Number: Print last name,first name and middle name or initial. Circle Jr., Sr., II, III, IV if applica-ble. You must supply a Driver's License Number, if you have one. If youdo not have a Driver's License Number, you must supply the last four dig-its of your Social Security Number. If you do not have a Social SecurityNumber, please write None in the boxes. 4a Address of Residence: Fill in your complete address of residence.P.O. boxes may not be used here unless there is no physical address.Print street address, city and zip code. (If the residence is only a portion ofthe house, include the location or number of the room, apartment or floorwhich is occupied.) In Box 4b include your telephone number. (Optional) In Box 4c fill in the name of the municipality (city, borough or town-ship) and county where you live. Use the map in the box below if you can-not otherwise identify your address.
If you checked "No" in response to either of thesequestions, do not complete this form.
Box 5.Box 6.Box 7.Box 8.
Name of Assistant: If the applicant is unable to sign the application, theperson who assisted the applicant must provide his or her name, addressand telephone number.
Box 12.
MrMrsMiss
DL #
OR SS# (last 4 digits)
( )
Voter IdentificationNumberI HEREBY DECLARE THAT:
PARTY AFFILIATIONYEARREGISTRARDATE OF REGISTRATION
PA
Jr Sr II III IV
Box 1.
Box 2.
Box 4.
Box 3.
Place either Driver's License # or Social Security # here
(1)On the day of the next election I will have been a United States citizen forat least one month, I will be at least 18 years of age, and I will haveresided in Pennsylvania and in my election district for at least 30 days;
(2)I am legally qualified to vote.
Box 9.
Box 10.
Box 11.
my voting residence in the county where I last resided.I am a Federal or State employee and wish to retain