New York State Voter Registration Form - PDF by dbh92952


									             New York State Voter Registration Form
   Instructions                                     Send or deliver this form                      Verifying your identity
                                                    Fill out the form on page 2 of this PDF        We’ll try to check your identity before
   With this form, you register to vote in          document and mail it to your county’s          Election Day, through the DMV number
   elections in New York State. You can also        address from the list of addresses below,      (driver’s license number or non-driver
   use this form to:                                or take the form to the office of your         ID number), or the last four digits of
   • change the name or address                     County Board of Elections.                     your social security number, which
     on your voter registration                                                                    you’ll fill in below.
                                                    Mail or deliver this form at least 25 days
   • become a member of                             before the election you want to vote           If you do not have a DMV or social
     a political party
                                                    in. Your county will notify you that you are   security number, you may use a valid
   • change your party membership
                                                    registered to vote.                            photo ID, a current utility bill, bank
                                                                                                   statement, paycheck, government check
   To register you must:                            Questions?                                     or some other government document that
   • be a US citizen;                               Call your County Board of Elections            shows your name and address. You may
   • be 18 years old by the end of this year;       listed on the back of this form or             include a copy of one of those types of ID
   • not be in prison or on parole                  1-800-FOR-VOTE(TDD/TTY Dial 711)               when you mail this form.
      for a felony conviction;                                                                     If we are unable to verify your identity
                                                    Find answers or tools on our website
   •	 not	claim	the	right	to	vote	elsewhere.                      before Election Day, you will be asked
                                                                                                   for ID when you vote for the first time.

   Información en español: si le interesa
   obtener este formulario en español,
   llame al 1-800-367-8683

   (Optional) Register to donate your organs and tissues
   If you would like to be an organ and tissue donor, you may enroll in the NYS Department of Health (DOH)
   Donate Life™ Registry online at or complete the form below and mail it in with your Voter
   Registration Form.
   You will receive a confirmation letter from DOH, which will also provide you an opportunity to limit your donation.

Last name                                                                                             By signing below,
                                                                                                      you certify that you are:
First name
                                                                                                    •	 18	years	of	age	or	older;
Middle Initial                     Suffix                                                           •	 consenting	to	donate	all	of	your	organs	and	
                                                                                                       tissues for transplantation, research, or both;
                                                                                                    •	 authorizing	the	Board	of	Elections	to	provide	
                                                                                                       your name and identifying information to
                                                                                                       DOH for enrollment in the Registry;
Apt. Number                                                Zip code                                 •	 and	authorizing	DOH	to	allow	access	to	this	
                                                                                                       information to federally regulated organ procure-
City                                                                                                   ment organizations and NYS-licensed tissue
                                                                                                       and eye banks and hospitals upon your death.
Birth date    M   M / D     D /   Y   Y     Y   Y          Sex         M          F

Eye color                                                  Height           Ft.              In.
                                                                                                                   Sign                        Date
New York State Voter Registration Form (See instructions on page 1)                                                                             Clear Form

     It is a crime to procure a false registration or to furnish false information to the Board of Elections.               Please print in blue or black ink.

                                               Are you a citizen of the U.S.?               Yes            No                     For board use only
                                               If you answer No, you cannot register to vote.
                                               Will you be 18 years of age or
                                       2       older on or before election day?             Yes            No
                                               If you answer No, you cannot register to vote unless you will be 18 by the end of the year.

                                               Last name                                                                            Suffix
Your name                              3
                                               First name                                                                           Middle Initial

                                       4       Birth date     M   M / D      D /   Y    Y    Y    Y                        5        Sex            M          F
More information
                                       6       Telephone (optional)                 –                  –

                                               Address	(not	P.O.	Box)

                                               Apt. Number                                        Zip code
The address                            7
where you live                                 City/Town/Village

                                               New York State County Please select your New York State County

                                               Address or P.O. Box
The address where
you receive mail                       8       P.O. Box                                           Zip code
Skip if same as above

Voting history                         9       Have you voted before?              Yes            No                  10       What year?

Voting information                             Your name was
that has changed                      11       Your address was
Skip if this has not changed or
you have not voted before                      Your previous state or New York State County was

Identification                                     New York State DMV number
You must make 1 selection             12           Last four digits of your Social Security number               x x x – x x –
For	questions,	please	refer	to	
Verifying your identity above.                     I do not have a New York State driver’s license or a Social Security number.

Political party                                    Democratic party                                   Affidavit: I swear or affirm that
You must make 1 selection                          Republican party                                   •	 I	am	a	citizen	of	the	United	States.
                                                                                                      •	 I	will	have	lived	in	the	county,	city	or	village	
                                                   Independence party                                    for at least 30 days before the election.
To vote in a primary election,
you must be enrolled in one           13           Conservative party                                 •	 I	meet	all	requirements	to	register	
of these listed parties —                                                                                to vote in New York State.
except	the	Independence	Party,	                    Working Families party                             •	 This	is	my	signature	or	mark	in	the	box		below.	
which permits non-enrolled voters                                                                     •	 The	above	information	is	true,	I	understand	that	
to participate in certain primary
                                                   Other                                     15          if it is not true, I can be convicted and fined up
elections.                                         I do not wish to enroll in a party                    to $5,000 and/or jailed for up to four years.

                                                  I need to apply for                                 Sign
                                                  an Absentee ballot (optional).
Optional questions                    14
                                                  I would like to be an
                                                  Election Day worker (optional).                     Date
Your address

                                                                              Your County Board of Elections address

  New York City          Chenango                Franklin              Lewis                  Oneida                Putnam                 Schuyler               Ulster
  Executive Offices      5 Court St.             355 West Main St.     7660 N. State St.      Union Station         25 Old Route 6         County Office Bldg.    284 Wall St.
  32 Broadway, 7th Fl.   Norwich, NY 13815       Ste. 161              Lowville, NY 13367     321 Main St.          Carmel, NY 10512       105 9th St., Unit 13   Kingston, NY 12401
  New York, NY           (607) 337-1760          Malone, NY 12953      (315) 376-5329         3rd Fl.               (845) 278-6970         Watkins Glen, NY       (845) 334-5470
  10004                                          (518) 481-1663                               Utica, NY 13501                              14891
                          Clinton                                      Livingston             (315) 798-5765        Rensselaer             (607) 535-8195         Warren
  (212) 487-5300
                          Cnty Government Ctr.   Fulton                County Govt. Ctr.                            Ned Pattison                                  Cnty. Municipal Ctr.
                          137 Margaret St.       2714 St. Hwy 29       6 Court St.            Onondaga              Government Ctr.        Seneca                 1340 St. Rte. 9
  Albany                  Ste. 104               Ste. 1                Room 104               Civic Ctr.            1600 Seventh Ave.      One DiPronio Dr.       Lake George, NY
  32 North Russell Road Plattsburgh, NY 12901    Johnstown, NY 12095   Geneseo, NY 14454      421 Montgomery St.,   Troy, NY 12180         Waterloo, NY 13165     12845
  Albany, NY 12206        (518) 565-4740         (518) 736-5526        (585) 243-7090         15th Fl.              (518) 270-2990         (315) 539-1760         (518) 761-6456
  (518) 487-5060                                                                              Syracuse, NY 13202
                          Columbia               Genesee               Madison                (315) 435-3312        Rockland               Steuben                Washington
  Allegany                401 State St.          County Building #1    County Office Bldg.                          11 New Hempstead Rd.   3 E. Pulteney Sq.      383 Broadway
  6 Schuyler St.          Hudson, NY 12534       15 Main St.           N. Court St.           Ontario               New City, NY 10956     Bath, NY 14810         Fort Edward, NY
  Belmont, NY 14813       (518) 828-3115         PO Box 284            PO Box 666             74 Ontario St.        (845) 638-5172         (607) 664-2260         12828
  (585) 268-9294                                 Batavia, NY 14021     Wampsville, NY 13163   Canandaigua, NY                                                     (518) 746-2180
                          Cortland               (585) 344-2550        (315) 366-2231         14424                 St. Lawrence           Suffolk
  Broome                  112 River St.                                                       (585) 396-4005        48 Court St.           PO Box 700             Wayne
  Government Plaza        Room 103               Greene                Monroe                                       Canton, NY 13617       Yaphank Ave.           157 Montezuma St. Ext.
  44 Hawley St.           Cortland, NY 13045     411 Main St.          39 Main St. W.         Orange                (315) 379-2202         Yaphank, NY 11980      PO Box 636
  PO Box 1766             (607) 753-5032         Ste. 437              Rochester, NY 14614    25 Court Lane                                (631) 852-4500         Lyons, NY 14489
  Binghamton, NY                                 Catskill, NY 12414    (585) 753-1550         PO Box 30             Saratoga                                      (315) 946-7400
  13902                   Delaware               (518) 719-3550                               Goshen, NY 10924      50 W. High St.         Sullivan
  (607) 778-2172          3 Gallant Ave.                               Montgomery             (845) 291-2444        Ballston Spa, NY       Gov’t. Ctr.            Westchester
                          Delhi, NY 13753        Hamilton              Old Courthouse                               12020                  100 North St.          25 Quarropas St.
  Cattaraugus             (607) 746-2315         Rte. 8                9 Park St.             Orleans               (518) 885-2249         PO Box 5012            White Plains, NY
  302 Court St.                                  PO Box 175            PO Box 1500            14012 State Rte. 31                          Monticello, NY 12701   10601
  Little Valley, NY 14755 Dutchess               Lake Pleasant, NY     Fonda, NY 12068        Albion, NY 14411      Schenectady            (845) 807-0400         (914) 995-5700
  (716) 938-2400          47 Cannon St.          12108                 (518) 853-8180         (585) 589-3274        388 Broadway, Ste. E
                          Poughkeepsie, NY       (518) 548-4684                                                     Schenectady, NY        Tioga                  Wyoming
  Cayuga                  12601                                        Nassau                 Oswego                12305                  County Office Bldg.    4 Perry Ave.
  10 Court St.            (845) 486-2473         Herkimer              240 Old Country Rd.    185 E. Seneca St.     (518) 377-2469         56 Main St.            Warsaw, NY 14569
  Auburn, NY 13021                               109 Mary St.          5th Fl.                Box 9                                        Owego, NY 13827        (585) 786-8931
  (315) 253-1285          Erie                   Ste. 1306             Mineola, NY 11501      Oswego, NY 13126    Schoharie                (607) 687-8261
                          134 W. Eagle St.       Herkimer, NY 13350    (516) 571-2411         (315) 349-8350      County Office Bldg.                             Yates
  Chautauqua              Buffalo, NY 14202      (315) 867-1102                                                   284 Main St.             Tompkins               Ste. 1124
  7 North Erie St.        (716) 858-8891                             Niagara                  Otsego              PO Box 99                Court House Annex      417 Liberty St.
  Mayville, NY 14757                             Jefferson           111 Main St.             Ste. 2              Schoharie, NY 12157      128 E. Buffalo St.     Penn Yan, NY 14527
  (716) 753-4580          Essex                  175 Arsenal St.     Ste. 100                 140 County Hwy. 33W (518) 295-8388           Ithaca, NY 14850       (315) 536-5135
                          7551 Court St.         Watertown, NY 13601 Lock port, NY 14094      Cooperstown, NY                              (607) 274-5522
  Chemung                 PO Box 217             (315) 785-3027      (716) 438-4040           13326
  378 South Main St.      Elizabethtown, NY                                                   (607) 547-4247
  PO Box 588              12932
  Elmira, NY 14902        (518) 873-3474
  (607) 737-5475

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