West Virginia Voter Registration Form

West Virginia Voter Registra on Applica on
Please follow these steps to complete this form. (Please PRINT in blue or black ink.)
Box 1. Indicate if this is a new registration,
party change, or name/address change.
Box 2.* Provide your full legal name, including any suffix
(Jr., Sr., III, etc.).
Box 3.* Provide your date of birth (MM/DD/YYYY). You
must be at least seventeen years old to apply to
register to vote and will be eighteen on or before
the next general elec on.
Box 4.* Enter your WV driver’s license or DMV issued
non-driver’s ID number. If you do not have a WV
driver’s license or DMV-issued ID, enter the last
four digits of your social security number. If you
do not have any of these numbers, enter the
word “NONE” and an ID number will be assigned
to you.
Box 5.* Line 1
Provide your residence address
(do not enter a P.O. Box).** Include the
name of the county where you reside.
Line 2
Provide your mailing address, if
different from your residence address. Check
the box if you reside within the city limits.
Box 8. Enter the address where you were last
registered to vote and the name under which
you were registered.
Box 9. Provide a telephone number (for Office Use
only).
Box 10. Select your party choice. If you do not
make a selection, you will be registered
as “unaffiliated”. Some political parties
may allow unaffiliated voters to cast a
ballot in their party’s primary election.
Box 11. Check if you would like to be contacted about
serving as a poll worker.
Box 12.* Carefully read the statement. If all of
the statement is true, then sign within
the box provided. Knowingly providing
false informa on is perjury, punishable on
convic on by confinement in a peniten ary
for not less than one nor more than ten years.
Box 6. Provide an email address (for Office Use only).
Box 7. Indicate your gender.
QUESTIONS:
REGISTRATION DEADLINE: You may submit a
registra on applica on at any me. However, in
order to vote in an election, you must register
twenty-one days before that elec on. For county
clerk informa on, including mailing address, please
visit www.wvsos.com.
If you are registering to vote for the first me in
West Virginia, or for the first me in this county
and you have not cast a vote in a federal elec on
in this state, you must submit a copy of a current
and valid ID with this applica on or the first me
you vote. To submit with this form, include:
1) a copy of a current and valid photo ID, or
2) a copy of a current u lity bill, bank statement,
government check, paycheck or other government
document that shows your name and current
residence address as provided on this applica on.
* Required informaƟon. Your registraƟon
cannot be processed without this informaƟon.
** Overseas ciƟzens who no longer reside in the
U.S. may enter the last address at which they
legally resided. Uniformed service voters should
check with the Federal VoƟng Assistance Program
for current instrucƟons: www.fvap.gov.
Contact your local county clerk or go to
www.wvsos.com
Call the West Virginia Secretary of State
toll-free 1-866-767-8683
FOR OFFICIAL USE
* Are you a ci zen of the United States of America?
* Will you be 18 years of age on or before the next
general elec on?
1
2*
5*
YES
YES
NO
NO
NEW REGISTRATION
LAST NAME
PARTY CHANGE
NAME/ADDRESS CHANGE
FIRST NAME
MIDDLE NAME
SUFFIX (Circle)
Jr.
Sr.
II
III
V
IV
RESIDENCE ADDRESS (HOUSE NUMBER/STREET NAME, CITY ZIP)
COUNTY
R-3
08/13
I LIVE WITHIN
CITY LIMITS
YOUR NAME AND ADDRESS WHERE YOU LAST REGISTERED TO VOTE
DEMOCRATIC
REPUBLICAN
10 PARTY:
I
WOULD
LIKE
TO
BE
A
POLL
WORKER
11
12* I swear or affirm that:
MOUNTAIN
• I am a ci zen of the United States;
• I am at least 17 years of age and will be 18 on or before
the next general elec on;
• My West Virginia residence address is listed in Box 5;
• I am not under convic on, proba on or parole for
elec on bribery, treason, or any felony; and
• I have not been judged incompetent by a court of
competent jurisdic on.
3*
DATE OF BIRTH
4*
DRIVER’S LICENSE # or
DMV ISSUED ID #:
/
VOTER ID:
/
ID CONFIRMATION:
If neither, enter the last four digits of
your Social Security #:
XXX-XX-
MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE ADDRESS)
8
PRECINCT:
If you answered “no” to either of these
questions, do not complete this form.
LIBERTARIAN
UNAFFILIATED
6
EMAIL (Office Use)
7
GENDER
9
TELEPHONE (Office Use)
M
DATE RECEIVED:
F
OTHER
SIGN YOUR NAME IN THE SPACE BELOW
PRECINCT:
YOU ARE SIGNING UNDER PENALTY OF PERJURY TO THE TRUTH
OF THE INFORMATION ON THIS APPLICATION
*
ITEMS MARKED WITH AN “ ” ARE REQUIRED FOR PROCESSING THIS APPLICATION.
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City
Zip
WV
County Courthouse
OFFICIAL ELECTION MATERIAL
CLERK OF THE COUNTY COMMISSION
POST OFFICE WILL NOT
DELIVER WITHOUT
POSTAGE
HERE
STAMP
Return Address
PLACE
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MUNICIPAL
SPECIAL ELECTION
MUNICIPAL
PRIMARY ELECTION
MUNICIPAL
GENERAL ELECTION
STATE-COUNTY
SPECIAL ELECTION
STATE-COUNTY
PRIMARY ELECTION
STATE-COUNTY
GENERAL ELECTION
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LAST NAME
DATE
FIRST NAME
MIDDLE INIT.
RECORD OF PARTY AFFILIATION
PARTY
PCT.
CLERK
RECORD OF NOTICES
(Record fact of vo ng with a check ( ) mark in the proper space. At
primaries record fact of vo ng by use of party ini al or ini als.)
DATE
TYPE
RESPONSE
CLERK
RECORD OF RESIDENCE
PCT.
CITY
ADDRESS
APT.OR
ROOMNO.
DATE
CLERK
OFFICE USE ONLY (Please remember to enter all information in the voter registration system)
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