68 New Jersey Voter Registration Application Please print clearly in ink. All information is required unless marked optional. 1 Check all boxes that apply: o New Registration o Address Change 2 Are you a U.S. Citizen? o Yes o No (If No, DO NOT complete this form) 4 Last Name 5 Date of Birth (MM / DD / YYYY) 7 NJ Driver's License Number or MVC Non-driver ID Number 8 3 o Name Change o Signature Update Are you at least 17 years of age? o Yes (If No, DO NOT complete this form) First Name / 6 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Clerk o No Middle Name or Initial / FOR OFFICIAL USE ONLY o Political Party Affiliation o Vote By Mail Gender (Optional) o Female Registration # Suffix (Jr., Sr., III) Office Time Stamp o Male If you DO NOT have a NJ Driver's License or MVC Non-Driver ID, provide the last 4 digits of your Social Security Number. __ __ __ __ o "I swear or affirm that I DO NOT have a NJ Driver's License, MVC Non-driver ID or a Social Security Number." Home Address (DO NOT use PO Box) Apt. Municipality (City/Town) County State Zip Code Apt. Municipality (City/Town) County State Zip Code o by mail o in person 10 Last Address Registered to Vote (DO NOT use PO Box) Apt. Municipality (City/Town) County State Zip Code Muni Code # 11 Former Name if Making Name Change 9 Mailing Address (If different from Home Address) 12 Party Day Phone Number (Optional) Ward E-Mail Address (Optional) 13 Do you wish to declare a political party affiliation? o Yes, the party name is (Optional) . District o No, I do not wish to be affiliated with any political party. 14 Request for Mail-In Ballot for all future elections (Optional) o I wish to receive a Mail-In Ballot for all future elections until I request otherwise in writing to the County Clerk's office. o Mail my ballot to the following address if different from Mailing Address above. State Zip Code Mailing Address if different from above Apt. Municipality (City/Town) Declaration - I swear or affirm that: l I am a U.S. Citizen l I live at the above home address l I am at least 17 years old, and understand that I may not vote until reaching the age of 18 l I will have resided in the State and county at least 30 days before the next election l I am not on parole, probation or serving a sentence due to a conviction for an indictable offense under any federal or state laws Signature of Registrant: Sign or mark and date on lines below Date X / / (MM / DD / YYYY) l I understand that any false or fraudulent registration may subject me to a fine of up to $15,000, imprisonment up to 5 years, or both pursuant to R.S. 19:34-1 If applicant is unable to complete this form, print the name and address of individual who completed this form. Name Date (MM / DD / YYYY) Address / / Important Instructions for sections 7, 8, 13 and 14 7) Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not supply any of the information required by section 7, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and valid photo ID, or a document with your name and current address on it to avoid having to provide identification at the polling place. Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers illegally shall be subject to criminal penalties. 8) If you are homeless, you may complete section 8 by providing a contact point or the location where you spend most of your time. 13) You may declare a political party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than 55 days before the primary election in order to vote in the primary election. Completing section 13 is OPTIONAL and will not affect the acceptance of your voter registration application. 14) If you wish to receive a Mail-In Ballot for all future elections, mark the appropriate box in section 14. You will continue to receive Mail-In Ballots for all future elections until you request otherwise in writing to your County Clerk's office. Need More Information? Check boxes below if you would like to receive more information about: o voting by mail o polling place accessibility o voting if you have a disability, including visual impairment o becoming a poll worker o available election materials in this alternative language: NJ Division of Elections - 08/24/18 New Jersey Voter Registration Information You can register to vote if: n You are a United States citizen. n You are at least 17 years of age.* n You will be a resident of the State and county 30 days before the election. n You are NOT currently serving a sentence, probation or parole because of a felony conviction. *You may register to vote if you are at least 17 years old but cannot vote until reaching the age of 18. Registration Deadline: 21 days before an election Your County Commissioner of Registration will notify you if your application is accepted. If it is not accepted, you will be notified on how to complete and/or correct the application. IMPORTANT: DO NOT ENLARGE, REDUCE OR MOVE the FIM and barcodes. They are only valid as printed! Special care must be taken to ensure FIM and barcode are actual size AND placed properly on the mail piece visit Elections.NJ.gov or call toll-free 1-877-NJVOTER to meet both USPS regulations and automation compatibility standards. Questions? 1 (1-877-658-6837) FOLD NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES BUSINESS REPLY MAIL FIRST-CLASS MAIL PERMIT NO. 206 TRENTON, NJ POSTAGE WILL BE PAID BY ADDRESSEE BERGEN COUNTY SUPERINTENDENT OF ELECTIONS 1 BERGEN COUNTY PLZ RM 380 HACKENSACK NJ 07601-9832 FOLD Artwork for User Defined (3.625" x 8.25") Layout: Envelope.LYT March 25, 2015 Important: Print out at 100% - DO NOT REDUCE. Produced by DAZzle, Version 12.2.02 (c) 1993-2012, DYMO Endicia, www.Endicia.com Authorized User, Serial # Fold as illustrated to ensure proper mailing. New Jersey Voter Registration You can register to vote if: n You are a United States citizen n You will be 18 years of age by the next election n You will be a resident of the county 30 days before the election n You are NOT currently serving a sentence, probation orparole because of a felony conviction Registration Deadline: 21 days before an election Your County Commissioner of Registration will notify you if your application is accepted. If it is not accepted, you will be notified on how to complete and/or correct the application. FOLD NJ DIVISION OF ELECTIONS PO BOX 304 TRENTON NJ 08625-9983 FOLD 1 fold top down 2 fold bottom up TAPE HERE Put both pages together as shown FOLD 3 2 3 Tape top shut 68 New Jersey Voter Registration Application Please print clearly in ink. All information is required unless marked optional. 1 Check all boxes that apply: o New Registration o Address Change 2 Are you a U.S. Citizen? o Yes o No (If No, DO NOT complete this form) 4 Last Name 5 Date of Birth (MM / DD / YYYY) 7 NJ Driver's License Number or MVC Non-driver ID Number 8 3 o Name Change o Signature Update Are you at least 17 years of age? o Yes (If No, DO NOT complete this form) First Name / 6 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Clerk o No Middle Name or Initial / FOR OFFICIAL USE ONLY o Political Party Affiliation o Vote By Mail Gender (Optional) o Female Registration # Suffix (Jr., Sr., III) Office Time Stamp o Male If you DO NOT have a NJ Driver's License or MVC Non-Driver ID, provide the last 4 digits of your Social Security Number. __ __ __ __ o "I swear or affirm that I DO NOT have a NJ Driver's License, MVC Non-driver ID or a Social Security Number." Home Address (DO NOT use PO Box) Apt. Municipality (City/Town) County State Zip Code Apt. Municipality (City/Town) County State Zip Code o by mail o in person 10 Last Address Registered to Vote (DO NOT use PO Box) Apt. Municipality (City/Town) County State Zip Code Muni Code # 11 Former Name if Making Name Change 9 Mailing Address (If different from Home Address) 12 Party Day Phone Number (Optional) Ward E-Mail Address (Optional) 13 Do you wish to declare a political party affiliation? o Yes, the party name is (Optional) . District o No, I do not wish to be affiliated with any political party. 14 Request for Mail-In Ballot for all future elections (Optional) o I wish to receive a Mail-In Ballot for all future elections until I request otherwise in writing to the County Clerk's office. o Mail my ballot to the following address if different from Mailing Address above. State Zip Code Mailing Address if different from above Apt. Municipality (City/Town) Declaration - I swear or affirm that: l I am a U.S. Citizen l I live at the above home address l I am at least 17 years old, and understand that I may not vote until reaching the age of 18 l I will have resided in the State and county at least 30 days before the next election l I am not on parole, probation or serving a sentence due to a conviction for an indictable offense under any federal or state laws Signature of Registrant: Sign or mark and date on lines below Date X / / (MM / DD / YYYY) l I understand that any false or fraudulent registration may subject me to a fine of up to $15,000, imprisonment up to 5 years, or both pursuant to R.S. 19:34-1 If applicant is unable to complete this form, print the name and address of individual who completed this form. Name Date (MM / DD / YYYY) Address / / Important Instructions for sections 7, 8, 13 and 14 7) Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not supply any of the information required by section 7, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and valid photo ID, or a document with your name and current address on it to avoid having to provide identification at the polling place. Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers illegally shall be subject to criminal penalties. 8) If you are homeless, you may complete section 8 by providing a contact point or the location where you spend most of your time. 13) You may declare a political party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than 55 days before the primary election in order to vote in the primary election. Completing section 13 is OPTIONAL and will not affect the acceptance of your voter registration application. 14) If you wish to receive a Mail-In Ballot for all future elections, mark the appropriate box in section 14. You will continue to receive Mail-In Ballots for all future elections until you request otherwise in writing to your County Clerk's office. Need More Information? Check boxes below if you would like to receive more information about: o voting by mail o polling place accessibility o voting if you have a disability, including visual impairment o becoming a poll worker o available election materials in this alternative language: NJ Division of Elections - 08/24/18 New Jersey Voter Registration Information You can register to vote if: n You are a United States citizen. n You are at least 17 years of age.* n You will be a resident of the State and county 30 days before the election. n You are NOT currently serving a sentence, probation or parole because of a felony conviction. *You may register to vote if you are at least 17 years old but cannot vote until reaching the age of 18. Registration Deadline: 21 days before an election Your County Commissioner of Registration will notify you if your application is accepted. If it is not accepted, you will be notified on how to complete and/or correct the application. Questions? visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837) FOLD Important: Print out at 100% - DO NOT REDUCE. Fold as illustrated to ensure proper mailing. New Jersey Voter Registration You can register to vote if: n You are a United States citizen n You will be 18 years of age by the next election n You will be a resident of the county 30 days before the election n You are NOT currently serving a sentence, probation orparole because of a felony conviction Registration Deadline: 21 days before an election Your County Commissioner of Registration will notify you if your application is accepted. If it is not accepted, you will be notified on how to complete and/or correct the application. FOLD FOLD Put both pages together as shown FOLD 1 fold top down 2 fold bottom up TAPE HERE 2 3 FOLD NJ DIVISION OF ELECTIONS PO BOX 304 TRENTON NJ 08625-9983 1 3 Tape top shut 76 New Jersey Voter Registration Application Please print clearly in ink. All information is required unless marked optional. 1 Check boxes that apply: o New Registration o Name Change 2 Are you a U.S. Citizen? o Yes o No (If No, DO NOT complete this form) 3 Last Name o Address Change o Signature Update o Political Party Affiliation or Non-Affiliation Change FOR OFFICIAL USE ONLY Are you at least 17 years of age? o Yes o No (If No, DO NOT complete this form) First Name Clerk Middle Name or Initial Suffix (Jr., Sr., III) Registration # Office Time Stamp 4 Date of Birth 5 NJ Driver’s License Number or MVC Non-driver ID Number If you DO NOT have a NJ Driver’s License or MVC Non-Driver __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ID, provide the last 4 digits of your Social Security Number. o “I swear or affirm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.” Apt. Municipality County State Zip Code 7 Mailing Address if different from above Apt. Municipality County State Zip Code 8 Last Address Registered to Vote (DO NOT use PO Box) Apt. Municipality County State Zip Code 6 Home Address (DO NOT use PO Box) 9 Former Name if Making Name Change o by mail o in person a. Day Phone Number (Optional) b. E-Mail Address (Optional) 10 Do you wish to declare a political party affiliation? (Optional) 11 Gender o Female o Male Declaration - I swear or affirm that: l I am a U.S. Citizen l I live at the above address l I am at least 17 years old, and understand that I may not vote until reaching the age of 18. o Yes, the party name is o No, I do not wish to be affiliated with any political party. l I will have resided in the State and county at least 30 days before the next election l I am not on parole, probation or serving a sentence due to a conviction for an indictable offense under any federal or state laws Signature: Sign or mark and date on lines below X Date . l I understand that any false or fraudulent registration may subject me to a fine of up to $15,000, imprisonment up to 5 years, or both pursuant to R.S. 19:34-1 If applicant is unable to complete this form, print the name and address of individual who completed this form. Name Date Address Important Instructions for sections 5, 6 and 10 5) Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not have any of the information required by section 5, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and valid photo ID, or a document with your name and current address on it to avoid having to provide identification at the polling place. Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers illegally shall be subject to criminal penalties. 6) If you are homeless, you may complete section 6 by providing a contact point or the location where you spend most of your time. 10) You may declare a political party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than 55 days before the primary election in order to vote in the primary election. Completing section 10 is OPTIONAL and will not affect the acceptance of your voter registration application. Need More Information? Check boxes below if you would like to receive more information about: o voting by mail o becoming a poll worker o polling place accessibility o voting if you have a disability, including visual impairment o available election materials in this alternative language: For further information visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837) NJ Division of Elections - 03/16/16 New Jersey Voter Registration Information You can register to vote if: n You are a United States citizen. n You are at least 17 years of age.* n You will be a resident of the State and county 30 days before the election. n You are NOT currently serving a sentence, probation or parole because of a felony conviction. *You may register to vote if you are at least 17 years old but cannot vote until reaching the age of 18. Registration Deadline: 21 days before an election Your County Commissioner of Registration will notify you if your application is accepted. If it is not accepted, you will be notified on how to complete and/or correct the application. Questions? visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837) 1 FOLD 2 FOLD Important: Print out at 100% - DO NOT REDUCE. Fold as illustrated to ensure proper mailing. New Jersey Voter Registration You can register to vote if: n You are a United States citizen n You will be 18 years of age by the next election n You will be a resident of the county 30 days before the election n You are NOT currently serving a sentence, probation orparole because of a felony conviction Registration Deadline: 21 days before an election Your County Commissioner of Registration will notify you if your application is accepted. If it is not accepted, you will be notified on how to complete and/or correct the application. FOLD NJ DIVISION OF ELECTIONS PO BOX 304 TRENTON NJ 08625-9983 FOLD fold top down 2 fold bottom up TAPE HERE 1 3 Put both pages together as shown FOLD 3 Tape top shut