1111 11:38:01 am. 11?07?2017 2/2

flame Hewlett SfEPl-tEtiilE??Vlr-J

 

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g- trat. A ?cation The downloadablet?pnntable online form l5 avat
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This to: CNN Registration [macaw UpdaieiChenge Address, Party Af?liation. Name. Signature) Diequeei: to Replace Voter lnfonnatlon Cant

OFFICIAL use ONLY Fl. {Eff-.51
-3959 

 
 
   
   
   
    

Are you a citizen of the United States of America? YES 0 ND

 

 

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laf?nn that I am not a convicted felon. or if I am. my right to vote has been restored. "Pi:
laffirrn that I have not been adjudicated mentally incapacitated with respect to voting .or. If] have, my right to vote has been restored.

Dale oreinh (MM-oo-rw'lf_n_q FL Lastti digits ofSocial Ihave

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Florida Driver License (FL Of.) or Florida Identi?cation (FL to) Card Number DL or FL Security Number NONE 
then 
1 . . these 
numbers. 
Last Name First Name Hid le Nil-ine? it Name Suffix 
\Bqnnan ?5110 
Address Where You Live (legal residence-no P.0- Bo ApULoUUnii 'City unly Zip Code-?1?
\32'03? (7451?! tie-51? a?oat lira-S" ?l 
. Mailing Address ApiILoflUmt Cify Nh"? ?utter-Country?. . .212 C?d? 
Address Where You Were Last Registered to Vote ApULol/Unit City - StahF Zip Code
.9 mow anntudqj?t?ii/?/ .44, La 53/33 .
Fo'rn?ier Nar'ne (if name is changed) 6 rider State or Coun of Birth Telephone No. (optionalEmail me SAMPLE BALLOTS if option is available In 61y county. 71., 1:
See?iblt'o?acnnt Notice.abnue}_ Hyuemail address isParty Affiliation (Check only one) (Check onlyr one ifappliceble) i will i
(Chad? only one. ?left a American l?di??fNaSka? Native 0 I am an active duty Uniformed Services or Merchant need 
2 3 legislated wmwutpa?i' Wharton) Asianjpacj?c Islander Marine member assistance 1
Black. not of Hispanic Origin I am a spouse or a dependent of an active duty uniformed With 5
epu tarty lepanic services or merchant marine member 2
?mam" its not oins anic cm i - - - 
i Minor party (print party nameU5. citizen residing outstde the us. Interested in 
Mu?t-raual 
i becoming a 5
Other. poll worker.
Oath: I do solemnly swear (or all'i'nn} that i will tact
and defend the Constitution at the United Stats: and am
the Consfinrfion or the State at Florida. that am MARK
quali?ed to register as an elector under the HERE t. 7
Constitution and laws of the State or Florida. and that 



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