Nebraska Voter Registration Form

NEBRASKA VOTER REGISTRATION APPLICATION
1. AreyouacitizenoftheUnitedStatesofAmerica?
Yes
No
2. Areyouatleast18yearsofage,orwillyoube18yearsofageonorbefore
the1stTuesdayfollowingthe1stMondayinNovemberofthisyear?
Yes
No
If you marked NO to either of the questions above, STOP.
Do not complete this application.
Print your full and complete Legal Name to avoid errors and duplicate registrations
Nebraska Secretary of State's
OfficialVoterRegistrationApplication
www.sos.ne.gov
FirstMiddleInitialLastSuffixorPreviousLastName
_________________________________________________________________________________________________________
DateofBirth(MM/DD/YYYY)
/
PlaceofBirth
/
__________________________________________
NebraskaDriver’sLicenseNumber
Last4digitsSSN,ifnoNeb.DL#
Registeredat:PrintyourStreetNumber,StreetName,City,State,Zip
_________________________________________________________________________________________________________
MailingAddress,ifdifferent:_______________________________________________________________
Please print your previous registration information (Providing this information avoids errors and duplicate registrations)
____________________________/____________________________________________________
Name
Address
Important - Party Affiliation - Please Mark One
Democratic
Other
Republican
Libertarian
Nonpartisan
_______________________________________________________________
If checking other, print the name of the party
Note: If you wish to vote in both partisan and nonpartisan primary elections for the state and local offices,
you must indicate a political party affiliation on the registration application. If you register without a political
party affiliation (nonpartisan), you will receive only the nonpartisan ballots for the state and local offices at
primary elections. If you register without a political party affiliation (nonpartisan), you may vote in partisan
primaryelectionsforcongressionaloffices.
Optional-Toassistinverifyinginformation,pleaseprovide:
PhoneNumber()
Check the box if any are private.
CellNumber()
Email
Applicant’sOath:Tothebestofmyknowledgeandbelief,Ideclareunderpenaltyofelectionfalsification,that:
(1)IliveintheStateofNebraskaattheaddressprovidedinthisapplication;(2)Ihavenotbeenconvictedofa
felonyor,ifconvictedithasbeenatleasttwoyearssinceIcompletedmysentenceforthefelony,includingany
paroleterm;(3)Ihavenotbeenofficiallyfoundtobenoncomposmentis(mentallyincompetent);and(4)Iama
citizenoftheUnitedStates.
Instructions for Registering to Vote Using this Application
1. Completetheapplicationonlyifyoucheck‘yes’toquestions1and2.
2. UsethisapplicationtoregistertovoteinNebraskaortoupdateyourname,
address,orpartyonyourNebraskavoterregistrationrecord.
3. Clearlyprintalltherequestedinformationinthedesignatedspaces.
4. Readtheoath,verifytheinformationbysigninganddatingtheapplication.
5. Returnthecompletedformtoyourcountyelectionoffice.
ByMail-mustbepostmarkedthe3rdFridaypriortotheelection.(Ifyou
aremailingthisapplicationandareafirsttimeregistrantinNebraska,
statutesrequireacopyofacurrentandvalidphotoidorotherdated
personalgovernmentdocument.)
Bypersonalmessenger/agent-mustbedeliveredtoyourcountyelection
officebythe3rdFridaypriortotheelection.
Inperson-mustappear atyourcountyelectionofficeby6p.m.onthe
2ndFridaypriortotheelection.
6. TheCountyElectionofficewillsendeither:
Anacknowledgmenttoyouverifyingtheinformationonyourapplication
andadvisingyouofyourpollinglocation,or
Anincompletenoticetoyourequestingadditionalinformationtoensure
yourvoterregistrationrecordisaccurate,or
Arequestforvalidphotoid,orgovernmentdocumentifyouareafirst
timeregistrantinNebraska,registeringbymail.
WARNING: Any registrant who signs this application knowing that any of the information in the application is false shall be
guilty of a Class IV felony under section 32-1502 of the statutes of Nebraska. The penalty for a Class IV Felony is up to five years
imprisonment, a fine of up to $10,000.00 or both.
7. Ifyouhavequestions,youmaycontactyourlocalelectionoffice,oryou
maycontacttheNebraskaSecretaryofStatebyphoneat402-471-2555
ortollfreeat888-727-0007;viaourwebsite:www.sos.ne.gov;oremail
[email protected]
Source:V O T E
Form07012013
DateApplicationReceivedinElectionOffice:_____________________________ RegistrationTakenby:____________________
8. MailingaddressesfortheNebraskaCountyElectionOfficesmaybefoundon
thebackofthisapplication.
Applicant’sSignature:
Date:
(Address)
_________________
(Zip)
First Class
Postage Required
Cheyenne / POB 217
Sidney / 69162
Clay / 111 W Fairfield St
Clay Center / 68933
Colfax / 411 E 11th St
Schuyler / 68661
Cuming / 200 S Lincoln St.
Rm 100 / West Point / 68788
Custer / 431 S 10th St
Broken Bow / 68822
Dakota / POB 39
Dakota City / 68731
Dawes / 451 Main St
Chadron / 69337
Dawson / 700 N Washington
Rm A / Lexington / 68850
Deuel / POB 327
Chappell / 69129
Dixon / POB 546
Ponca / 68770
Dodge / 435 N Park Rm102
Fremont / 68025
Douglas / 225 N 115 St
Omaha / 68154
Dundy / Box 506
Benkelman / 69021-0506
Fillmore / POB 307
Geneva / 68361
Franklin / POB 146
Franklin / 68939
Frontier / POB 40
Stockville / 69042
Adams / POB 2067
Hastings / 68902-2067
Antelope / PO Box 26
Neligh / 68756-0026
Arthur / POB 126
Arthur / 69121
Banner / POB 67
Harrisburg / 69345
Blaine / 145 Lincoln Ave
Brewster / 68821
Boone / 222 S 4th St
Albion / 68620-1247
Box Butte / POB 678
Alliance / 69301
Boyd / POB 26
Butte / 68722
Brown / 148 W 4th St
Ainsworth / 69210
Buffalo / POB 1270
Kearney / 68848
Burt / POB 87
Tekamah / 68061
Butler / 451 N 5th St
David City / 68632
Cass / 201 Main St
Plattsmouth / 68048
Cedar / POB 47
Hartington / 68739
Chase / POB 1299
Imperial / 69033
Cherry / POB 120
Valentine / 69201
Jefferson / 411-4th St
Fairbury / 68352
Howard / POB 25
St Paul / 68873
Hooker / Box 184
Mullen / 69152
Holt / POB 329
O’Neill / 68763
Hitchcock / POB 248
Trenton / 69044
Hayes / POB 370
Hayes Center / 69032
Harlan / Box 698
Alma / 68920-0698
Hamilton / 1111-13th St Ste 1
Aurora / 68818-2017
Hall / 121 S Pine St
Grand Island / 68801
Greeley / Box 287
Greeley / 68842
Grant / Box 139
Hyannis / 69350
Gosper / POB 136
Elwood / 68937
Garfield / POB 218
Burwell / 68823-0218
Garden / POB 350
Oshkosh / 69154
Gage / POB 429
Beatrice / 68310
Furnas / POB 387
Beaver City / 68926
Nemaha / 1824 N St Ste 201
Auburn / 68305
Nance / POB 338
Fullerton / 68638
Morrill / POB 610
Bridgeport / 69336
Merrick / POB 27
Central City / 68826
McPherson / PO Box 122
Tryon / 69167
Madison / POB 290
Madison / 68748
Loup / POB 187
Taylor / 68879
Seward / POB 190
Seward / 68434
Scottsbluff / 1825 10th St
Gering / 69341
Saunders / POB 61
Wahoo / 68066
Sarpy / 501 Olson Dr Ste 4
Papillion / 68046
Saline / POB 865
Wilber / 68465
Rock / POB 367
Bassett / 68714
Richardson / 1700 Stone St
Room 203 / Falls City / 68355
Red Willow / 502 Norris Ave
McCook / 69001
Polk / POB 276
Osceola / 68651
Lincoln / 301 N Jeffers Rm 101
North Platte / 69101
Logan / POB 8
Stapleton / 69163
Platte / PO Box 513
Columbus / 68602-0513
Pierce / 111 W Court Rm 1
Pierce / 68767
Phelps / Box 404
Holdrege / 68949
Perkins / POB 156
Grant / 69140
Pawnee / POB 431
Pawnee City / 68420
Otoe / POB 249
Nebraska City / 68410
Nuckolls / POB 366
Nelson / 68961
Lancaster / 601 N 46th St
Lincoln / 68503
Knox / POB 166
Center / 68724
Kimball / 114 E 3rd St Ste 6
Kimball / 69145
Keya Paha / POB 349
Springview / 68778
Keith / 511 N Spruce Ste 102
Ogallala / 69153
Kearney / POB 339
Minden / 68959
Johnson / Box 416
Tecumseh / 68450
York / 510 Lincoln Ave
York / 68467
Wheeler / POB 127
Bartlett / 68622
Webster / POB 250
Red Cloud / 68970
Wayne / 510 Pearl St
Ste 5 / Wayne / 68787
Washington / POB 466
Blair / 68008
Valley / 125 S 15th St
Ste 202 / Ord / 68862
Thurston / POB 159
Pender / 68047
Thomas / POB 226
Thedford / 69166
Thayer / 225 N 4th Rm201
Hebron / 68370
Stanton / POB 347
Stanton / 68779
Sioux / POB 158
Harrison / 69346
Sherman / POB 456
Loup City / 68853
Sheridan / POB 39
Rushville / 69360
Find your county listed in red below. Print the name & address in the space provided above. Detach, stamp and mail.
(City or Town)
______________________________________ , Nebraska
______________________________________
(County)
To:______________________________________ County Election Official
________________________________________
________________________________________
________________________________________
Print Your Return Address