Req Indiv Voter Info Form

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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

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