Request for Voter Registration Information
TO: The Middlesex County Board of Elections (Questions: Kathy - 732-745-3471) I hereby request voter information on the following individual: Name: ______________________________________________________________
(Please Print)
Address: ______________________________________________________________ City/Zip: ___________________________________________________________________________ Unique Identifier such as last 4 digits of Social Security number, birth date, driver’s license number (If available) _______________________________________________ Information Requested
(Check all that apply)
Office Use Only
(Information requested will be entered here)
Are they registered Current Address
Yes
No
Mailing Address
(If different than current)
Party Affiliation Voting History
(Which elections they voted in)
Who provided this info: Requestor Information My name is: Company Address
(Please Print)
(if applicable)
(Street) (City/State/Zip)
Phone and Fax Number
Phone
(Version 2 - June 2004)
Fax
CERTIFICATION: I certify that the information requested is not for commercial solicitation per New Jersey Statute 19:31-18.1c.
_______________________ Date
________________________________ Signature
Send completed form with fee to: Board of Elections, 777 Jersey Ave., New Brunswick, NJ 08901-3605