West Virginia Voters Registration Form : simplebooklet.com

West Virginia Voter Registration ApplicationPlease read the instructions below. Note: Your registration cannot be processed without your full legal name, date of birth, driver’s license or state ID number (unless none), residence address, afﬁ rmation of eligibility, and signature. Please print in blue or black ink.Line 1 Mark if this is a new registration, party change, or name/address change.Line 2 Provide your full legal name, including any sufﬁ x (such as Jr., Sr., III), date of birth, and gender. You must be at least 17 years of age and 18 by the next general election to register to vote.Line 3 Enter your DMV issued driver’s license or state ID number. If you do not have a driver’s license or state ID, enter the last four numbers of your social security number. If you do not have any of these numbers, enter the word “NONE,” and a voter ID number will be assigned to you.Line 4 Provide your residence address (the address where you live). Check the box if you live within city limits. Include the name of the county where you live.Line 5 Provide the address where you receive mail, if different than your residence address. Enter a telephone number (for ofﬁ ce use only) and email (for ofﬁ ce use only).Line 6 Select your party choice. You may vote a party primary ballot only if you are registered with that party; however, parties may allow voters who are not afﬁ liated with their party to vote their ballot upon request.Line 7 Enter the address where you were last registered to vote and the name under which you were registered.Line 8 Mark if you would like to be contacted about serving as a poll worker.Line 9 Carefully read each statement. If the statements are true, check the boxes, sign, and date. Knowingly providing false information is perjury, punishable on conviction by conﬁ nement in a penitentiary for not less than one nor more than ten years.Voter Registration Deadline: This registration application will be in effect for the next election if mailed or delivered to your county clerk at least 21 days before the next election. For county clerk contact information, go to www.wvsos.gov.First Time Voters: If you are registering to vote for the ﬁ rst time in W.V., or for the ﬁ rst time in this county, and you have not cast a vote in a federal election in this state, you must submit a copy of a current and valid ID with this application or show it the ﬁ rst time you vote. To submit with this form, include: 1) a copy of a current and valid photo ID, or 2) a copy of a current utility bill, bank statement, government check, paycheck or other government document that shows your name and current residence address.Overseas Citizens and Uniformed Service Voters: Overseas citizens who no longer reside in the United States may enter the last address at which they legally resided. Uniformed service voters should check with the Federal Voting Assistance Program for current instructions at www.fvap.gov.Questions: Contact your County Clerk, go to www.wvsos.gov, or call the W.V. Secretary of State toll-free at 1-866-767-8683Required* (in bold): Full legal name, date of birth, driver’s license or ID number (unless none), residence address, afﬁ rmation of eligibility, signatureI swear or afﬁ rm that:*o I am a citizen of the United States;o I am at least 17 years of age and will be 18 on or before the next general election;o I am a legal resident of W.V. and of the county where I am applying;o I am not currently under conviction, probation or parole for election bribery, treason, or any felony; and o I have not been judged incompetent by a court of competent jurisdiction.Date:______________________Signature*You are signing under penalty of perjury to the truth of the information on this application.123456789o New Registration o Party Change o Name/Address ChangeLast Name* First Name* Middle Name* Sufﬁ xGender o Fo MDate of Birth*__ __ / __ __ / __ __ __ __Month Day YearYour name and address where you last registered to voteResidence Address (where you live)*Street __________________________________ Apt/Unit ____________ o I live within city limits W.V.City/Town_____________________________ State ________Zip Code____________ County___________o I would like to be a poll workerWV DMV issued driver’slicense or state ID number:* ___ ___ ___ ___ ___ ___ ___Or last four digits of your SocialSecurity Number:* XXX - XX - __ __ __ __Contact Information (not for public use)Email _________________________Phone ________________________Mailing AddressStreet _______________________________________ Apt/Unit __________City/Town _________________________ State _______ Zip Code ________Party: o Democratic o Republican o Libertarian o Mountain o No party o Other __________________Precinct:Voter ID:ID Conﬁ rmation:Date Received:Precinct:R-309/19FOR OFFICIAL USEC199973 3906 WVSOS001.indd 1C199973 3906 WVSOS001.indd 1 8/27/19 12:56 PM8/27/19 12:56 PM

West Virginia Voters Registration Form

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