Voter Registration Form - State Board of Elections

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1 NORTH CAROLINA VOTER REGISTRATION APPLICATION 06w 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? Yes No IF YOU CHECKED "NO" IN RESPONSE TO THIS QUESTION, IF YOU CHECKED "NO" IN RESPONSE TO THIS QUESTION, DO NOT SUBMIT THIS FORM. DO NOT SUBMIT THIS FORM. Last Name (Required) Date of Birth MMDDYYYY (Required) State of Birth/Country of Birth 2 3 First Name (Required) If you know your NC Voter Registration Number, enter it below. Middle Name (Required) If you have a NC drivers license or non-operators ID card, enter the number below. Jr Sr II Enter the last 4 digits of your SSN. Check here if you do not have a NC III IV V drivers license, ID card, or a SSN. RESIDENTIAL ADDRESS INFORMATION - No P.O. Boxes or Rural Routes Street Address where you live (Required) Apartment, Lot, or Unit Number 4 City (Required) State Zip Code N C County If "No," date moved? MMDDYYYY Phone (Optional) Have you lived here Yes No for 30 days or more? MAILING ADDRESS MAP/DIAGRAM 5 Mailing Address (If different from your residential address) If you do not have a street address, draw a map of where you reside. Please include roads and landmarks. Mailing Address Line 2 City State Zip Code 6 GENDER RACE ETHNICITY POLITICAL PARTY AFFILIATION African American/ American Indian/ Hispanic/Latino Democrat Republican Libertarian Female Black Alaska Native Male Asian Multiracial Not Hispanic/ Latino Unaffiliated Other White 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.) Last Name used in Previous Registration First Name used in Previous Registration 7 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.) Fraudulently or falsely completing this form is a Class I Felony under Chapter 163 of the NC General Statutes. X Signature (Required) Date version102013

2 NC VOTER REGISTRATION APPLICATION INSTRUCTIONS Your may use this form to: Acceptable Identification (ID Requirements) Register to vote in your North Carolina county of residence. Help America Vote Act ID Under federal and state law, if you are registering to vote and cannot provide a valid ID number in Section 3, you should include a copy of Update your name, address, or party affiliation in the North Carolina county in one of the documents below with this application: which you are currently registered. A current and valid photo ID. Cancel your previous registration in another county or state. A current utility bill, bank statement, government check, paycheck, or other To be eligible to vote in the county in which you are registering: government document that shows your name and address. If you do not provide a valid ID number on your application or submit a copy of one You must be a U.S. citizen. of the documents noted above, you must show an ID the first time you vote. You must be at least 18 years of age by the date of the next general election. By election day, you must have resided in the county for at least 30 days. Photo ID Effective January 1, 2016, North Carolina voters will be asked to show a You must not be currently serving a felony sentence. If previously convicted of photo ID when voting in person. The acceptable types of photo ID are: a felony, you must have fully completed your sentence, including probation or parole. No special document is required. NC DMV drivers license (permits and provisional licenses too) NC DMV identification card Voter Registration and Declination Statement: United States passport The location or office where you submitted this application will remain confidential United States military identification card and will be used only for voter registration purposes. If you decline to register to Veterans Identification Card vote, the fact that you so declined will remain confidential. Tribal enrollment card issued by a federally or N.C. recognized tribe Registration Deadline: Out-of-state drivers license or ID card (may be shown only if newly regis- tered within past 90 days). This application must be received (or postmarked) by your county board of elec- tions no later than 25 days before the date of the first election in which you desire Expired IDs are acceptable under certain limitations. There are also special excep- tions for voters who have a religious objection to being photographed, voters eligible Submitting Your Form: for curbside voting, voters who are victims of a natural disaster, and voters who are unable to obtain a photo ID due to a reasonable impediment. For more information If registering for the first time in the county in which you presently reside, or if you concerning voter registration, voting and acceptable ID requirements, contact us at: are changing your party affiliation, your county board of elections must receive your originally signed application. If you are currently registered to vote in your county of residence and you are using this form to update your name, address, or other infor- mation, you may also fax or email a scanned image of your signed application. You 1-866-522-4723 or [email protected] should submit your signed application to your county board of elections. or visit our website at Visit www.ncsbe.gov for the address, fax number, or email address for your county www.NCSBE.gov board of elections. NC SBOE Revised 07/2015

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