For office use only Polling Place Date Pct Ward School House Senate Reg. #
TO REGISTER: All items, except where noted, must be completed to register to vote.
Under federal and/or state law, all electors must present ID when voting. 1. Are you a citizen of the United States of America? 2. Will you be 18 years of age on or before election day? Yes No* Yes No*
*Note: If you checked ‘no’ in response to either of these questions, do not complete this form.
3. MONTANA DRIVER’S LICENSE #________________________ You MUST provide your driver’s license number, if you have a driver’s license.
If you do not have a driver’s license, list the last four digits of your Social Security number on the line above. If you have neither a driver’s license nor a Social Security number, provide (in person) or enclose (by mail) a copy of one of the following: any photo ID with your name; OR a current utility bill, bank statement, paycheck, government check, or other government document that shows your name and current address.)
4. Email Address (optional)___________________________________________________
5. NAME
(Please print) Last First Middle
6. COUNTY_________________________ 7. ADDRESS WHERE YOU LIVE *
*Precinct is determined by address where you live.
9. TELEPHONE NUMBER _______________________________ 10. DATE OF BIRTH _____/_____/______
Month Day Year
________________________________ ________________________________
(Street, City, Zip OR Sec., Twp. & Range)
8. MAILING ADDRESS (If different than #7) ________________________________ ________________________________ 13. VOTER DECLARATION (Read and sign below)
11. PRINT FORMER NAME (if changed) _______________________________ 12. PLACE LAST REGISTERED _______________________________
CITY COUNTY STATE
I swear/affirm that: a) I am a U.S. citizen; b) I will be at least 18 years old on or before the next election; c) I will have lived in this county for at least 30 days before the next election (unless I am exempt under 13-2-514(2), MCA); d) I am neither in a penal institution for a felony conviction nor found of unsound mind by a court; e) If I do not now meet these qualifications, I will by the next election; and f) I have provided true information, to the best of my knowledge under penalty of perjury. If I have given false information, I may be subject to a fine or imprisonment or both under Federal or State laws.
14. SIGNATURE_________________________________________ DATE_______________
(Fold and tape closed here) ____________________________ ____________________________ ____________________MT______ Place Stamp Here
ELECTION ADMINISTRATOR ______________________________COUNTY ______________________________________ _______________________MT____________
County Beaverhead Big Horn Blaine Broadwater Carbon Carter Cascade Chouteau Custer Daniels Dawson Deer Lodge Fallon Fergus Flathead Gallatin Garfield Glacier Golden Valley Granite Hill Jefferson Judith Basin Lake Lewis & Clark Liberty Lincoln Madison
Election Administrator Address 2 S Pacific St No 3 Dillon MT 59725 PO Box 908 Hardin MT 59034 PO Box 278 Chinook MT 59523 515 Broadway St Townsend MT 59644 PO Box 887 Red Lodge MT 59068 Box 315 Ekalaka MT 59324 Box 2305 Great Falls MT 59403 Box 459 Fort Benton MT 59442 1010 Main Miles City MT 59301 Box 247 Scobey MT 59263 207 West Bell Glendive MT 59330 800 Main Anaconda MT 59711 Box 846 Baker MT 59313 712 W Main Lewistown MT 59457 800 S Main Kalispell MT 59901 311 W Main Rm 103 Bozeman MT 59715 Box 7 Jordan MT 59337 512 E Main Cut Bank MT 59427 PO Box 10 Ryegate MT 59074 Box 925 Philipsburg MT 59858 Courthouse Havre MT 59501 Box H Boulder MT 59632 Box 427 Stanford MT 59479 106 4th Ave E Polson MT 59860 Box 1721 Helena MT 59624 Box 459 Chester MT 59522 512 California Libby MT 59923 Box 366 Virginia City MT 59755
County McCone Meagher Mineral Missoula Musselshell Park Petroleum Phillips Pondera Powder River Powell Prairie Ravalli Richland Roosevelt Rosebud Sanders Sheridan Silver Bow Stillwater Sweet Grass Teton Toole Treasure Valley Wheatland Wibaux Yellowstone
Election Administrator Address Box 199 Circle MT 59215 Box 309 White Sulphur Springs MT 59645 Box 550 Superior MT 59872 200 W Broadway Missoula MT 59802 506 Main Roundup MT 59072 Box 1037 Livingston MT 59047 Box 226 Winnett MT 59087 Box 360 Malta MT 59538 20 4th Ave SW Conrad MT 59425 Box 270 Broadus MT 59317 409 Missouri Deer Lodge MT 59722 Box 125 Terry MT 59349 215 S 4th St Ste C Hamilton MT 59840 201 W Main Sidney MT 59270 400 2nd Ave S Wolf Point MT 59201 Box 47 Forsyth MT 59327 Box 519 Thompson Falls MT 59873 100 W Laurel Ave Plentywood MT 59254 155 W Granite Rm 208 Butte MT 59701 Box 149 Columbus MT 59019 Box 888 Big Timber MT 59011 Box 610 Choteau MT 59422 226 1st St S Shelby MT 59474 Box 392 Hysham MT 59038 501 Court Sq Box 2 Glasgow MT 59230 Box 1903 Harlowton MT 59036 PO Box 199 Wibaux MT 59353 Box 35002 Billings MT 59107