Here is your completed Application for Permit, Driver License or Non-Driver ID Card (Form MV-44).

Before
continuing, please verify that everything is correct on your form.

If all looks good, here are your next steps to applying for your NY learner’s permit.

▢ Make sure you’ve turned at least 16 years old.

❍Take a Practice test or two so you’re completely prepared for your written permit exam!
❍Gather the following items:
This completed application form.
❍

Your Social Security card.

❍

Proof of your age and identity.

❍

Payment for your permit fee.

❍

Your cost will vary based on your age and where you live. Check out the DMV’s fee chart for your specific
●

total.
▢ Make an Appointment with your local DMV office.
▢ Submit the above to the DMV agent, and take the written test and vision exam*.
▢ Walk away with your brand new permit!

* If you prefer not to take the DMV’s vision exam, you’ll need an Eye Test Report (Form MV-619) completed by your
eye doctor.
 APPLICATION FOR ENHANCED OR REAL ID PERMIT, DRIVER LICENSE OR NON-DRIVER ID CARD
PRINT CLEARLY IN BLUE OR BLACK INK. PAGE 1 OF 3
This form is also available at dmv.ny.gov OFFICE USE ONLY
09('/
Image #
MARK THE BOX OF THE TYPE OF DOCUMENT OR SERVICE YOU NEED mark all that apply

Upgrade
Document to EDL  Document to Real ID  Permit  card  Renewal 
Current Upgrade Current Learner ID Replacement  Change  NYS license in exchange for a license from another US
State, the District of Columbia or Canadian Province

IDENTIFICATION INFORMATION 'R\RXQRZKDYHRUGLG\RXHYHUKDYHD1HZ<RUN ID NUMBER ON NYS DRIVER LICENSE, LEARNER

}
'ULYHUOLFHQVH"  <HV 1R If “Yes”, enter the 9-digit ID number as it appears on the PERMIT, or NON-DRIVER ID CARD
/HDUQHUSHUPLW"  <HV 1R front of the license, learner permit, or non-driver ID card.
1RQGULYHU,'&DUG" <HV 1R Note: 7KHFRPELQDWLRQRI\RXULGHQWLILFDWLRQGRFXPHQWVPXVW
FULL LAST NAME SURYH\RXUIXOOQDPH<RXUIXOOQDPHZLOODSSHDURQ\RXUGRFXPHQW
'R\RXKDYHRUGLG\RXHYHUKDYHDGULYHUOLFHQVHWKDWLVYDOLGRUWKDW
Shivmath H[SLUHGZLWKLQWKHODVWWZR\HDUVLVVXHGE\DQRWKHU866WDWHWKH
FULL FIRST NAME 'LVWULFWRI&ROXPELDRUD&DQDGLDQ3URYLQFH" <HV 1R
Sharad ,I³<HV´ZKHUHZDVLWLVVXHG"BBBBBBBBBBBBBBBBBBBBBBBBBBBB
FULL MIDDLE NAME 'DWHRI([SLUDWLRQ7\SHRI/LFHQVH2XWRI6WDWH/LFHQVH,'1R
Suresh
SUFFIX DATE OF BIRTH SEX HEIGHT EYE COLOR TELEPHONE NUMBER
0RQWK 'D\ <HDU 0DOH)HPDOH )HHW,QFKHV Area Code
07 13 1988 5 4 Brown ((917)) 825-8126
+DV\RXUQDPHFKDQJHG" <HV 1R If “Yes”, print your former
name exactly as it appears on your present license or non-driver ID card. MOBILE PHONE NUMBER EMAIL
Area Code
( )
(917) 825-8126 sharad.shivmath@gmail.com
SOCIAL SECURITY NUMBER* (SSN) * <RX PXVW SURYLGH \RXU 661$XWKRULW\ WR FROOHFW \RXU 661 LV JUDQWHG E\ 6HFWLRQV  DQG  RI WKH 9HKLFOH DQG
7UDIILF /DZ 7KH LQIRUPDWLRQ ZLOO EH XVHG RQO\ IRU H[FKDQJH ZLWK RWKHU MXULVGLFWLRQV WR DVVLVW LQ YHULILFDWLRQ RI
440857202 LGHQWLW\DQGWRLQYRNHGULYHUOLFHQVHVDQFWLRQVSXUVXDQWWR9 7/DZ6HFWLRQHDQGI<RXUQXPEHUZLOOQRWEHJLYHQWR
WKHSXEOLFRUDSSHDURQDQ\IRUPRULQIRUPDWLRQUHTXHVW
ADDRESS WHERE YOU GET YOUR MAIL
- Include Street Number and Name, Rural Delivery and/or box number (If PO Box, also fill in “Address Where You Live” below)
$SW1R &LW\RU7RZQ 6WDWH =LS&RGH &RXQW\

9101, 48th ave Elmhurst N Y 11373 Queens

ADDRESS WHERE YOU LIVE REQUIRED IF DIFFERENT FROM ADDRESS FOR MAIL - DO NOT GIVE P.O. BOX. THIS ADDRESS WILL APPEAR ON YOUR DRIVER LICENSE.
$SW1R &LW\RU7RZQ 6WDWH =LS&RGH &RXQW\

HAS YOUR MAILING ADDRESS CHANGED? <HV 1R HAS THE ADDRESS WHERE YOU LIVE CHANGED? <HV 1R
,I\RXDQVZHUHG\HVWRHLWKHURIWKHTXHVWLRQVDERYHWKHQDGGUHVVHVRQDOOYHKLFOHUHJLVWUDWLRQVWLHGWR\RXU,'QXPEHUZLOODOVREHXSGDWHGZLWKWKLVDGGUHVVXQOHVV\RX
FKHFNWKLVER[,I\RXDUHUHJLVWHUHGWRYRWH\RXUYRWHUUHJLVWUDWLRQUHFRUGZLOOEHXSGDWHGZKHQ\RXFRPSOHWHDQGVXEPLWWKLVIRUP,I\RXGR127ZDQW\RXUQHZDGGUHVV
RQ\RXUYRWHUUHJLVWUDWLRQUHFRUGFKHFNWKLVER[,I\RXGRQRWFKHFNWKHER[\RXUQHZDGGUHVVZLOOEHVHQWWRWKH%RDUGRI(OHFWLRQVRI\RXUFRXQW\RIUHVLGHQFH

:KDWLVWKHFKDQJHDQGWKHUHDVRQIRULW
OTHER CHANGE: QHZOLFHQVHFODVVZURQJGDWHRIELUWKHWF"

VETERAN STATUS &KHFNWKLVER[LI\RXZRXOGOLNHWRKDYH³9HWHUDQ´SULQWHGRQWKHIURQWRI\RXUSKRWRGRFXPHQW

<RXPXVWSUHVHQWSURRIWKDWLQGLFDWHVDQKRQRUDEOHGLVFKDUJHIURPPLOLWDU\VHUYLFH)RUDGGLWLRQDOLQIRUPDWLRQSOHDVHVHHIRUP09('/
NEW YORK STATE ORGAN AND TISSUE DONATION (You must fill out the following section)
60
 &KHFNWKLVER[WRPDNHD
7RHQUROOLQWKH1HZ<RUN6WDWH'RQDWH /LIH5HJLVWU\FKHFNWKH³\HV´ER[DQGWKHQVLJQDQGGDWHEHORZ<RXDUHFHUWLI\LQJWKDW\RXDUH\HDUVRI  YROXQWDU\GRQDWLRQWR WKH
DJH RU ROGHU FRQVHQWLQJ WR GRQDWH \RXU RUJDQV DQG WLVVXHV IRU WUDQVSODQWDWLRQ DQG UHVHDUFK DXWKRUL]LQJ '09 WR WUDQVIHU \RXU QDPH DQG LGHQWLI\LQJ /LIH3DVV,W2Q7UXVW)XQG
LQIRUPDWLRQ WR WKH 'RQDWH /LIH 5HJLVWU\ DQG DXWKRUL]LQJ 'RQDWH /LIH 1<6 WR JLYH DFFHVV WR WKLV LQIRUPDWLRQ WR IHGHUDOO\ UHJXODWHG RUJDQ GRQDWLRQ IRURUJDQDQGWLVVXHGRQDWLRQ
RUJDQL]DWLRQVDQG1<6OLFHQVHGWLVVXHDQGH\HEDQNVDQGKRVSLWDOVXSRQ\RXUGHDWK³25*$1'2125´will be printed on the front of your DMV photo UHVHDUFKDQGRXWUHDFK<RXU
document <RX ZLOO UHFHLYH D FRQILUPDWLRQ  ZKLFK ZLOO DOVR SURYLGH \RX DQ RSSRUWXQLW\ WR OLPLW \RXU GRQDWLRQ ,I \RX DUH  RU  \HDUV RI DJH WRWDO WUDQVDFWLRQ IHH ZLOO
SDUHQWVOHJDOJXDUGLDQVPD\FKDQJH\RXUGHFLVLRQXSRQ\RXUGHDWK)RUPRUHLQIRUPDWLRQFRQWDFW'/1<6DWGRQDWHOLIHQ\JRY LQFOXGHWKH
You must answer the following question: :RXOG\RXOLNHWREHDGGHGWRWKH'RQDWH/LIH5HJLVWU\" <HVVLJQDQGGDWHFRQVHQWEHORZ
6NLS7KLV4XHVWLRQ
♥'RQRU&RQVHQW6LJQDWXUH t BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB'DWHBBBBBBBBBBBBB
VOTER REGISTRATION QUESTIONS (Please check “yes” or “no”. NOTE: ,I\RXGRQRWFKHFNHLWKHUER[\RXZLOOEHFRQVLGHUHGWRKDYHGHFLGHGQRWWRUHJLVWHUWRYRWH

,I\RXDUHQRWUHJLVWHUHGWRYRWHZKHUH\RXOLYHQRZZRXOG\RXOLNHWRDSSO\WRUHJLVWHU"
YES &RPSOHWH9RWHU5HJLVWUDWLRQ$SSOLFDWLRQ6HFWLRQ1RWQHFHVVDU\LI\RXEULQJWKLVIRUPWRD'09RIILFH NO ,'HFOLQHWR5HJLVWHU$OUHDG\5HJLVWHUHG
PLEASE COMPLETE AND SIGN PAGE 2.
F 2WKHU /LFHQVH A B C NCDL-C D DJ
O 5HVWULFWLRQV
&ODVV E ID M MJ
R (QGRUVHPHQWV
6SHFLDO AM DP LR TR LS BC
O &RQGLWLRQV
F &'/&HUWLILFDWLRQV NI NA EI EA ML NF TD UC UP UR X8 XT
F
3URRI6XEPLWWHG $SSURYHG%\ 'DWH
I 7((16
'ULYHU/LFHQVH,' '+6'RFXPHQWV 6RFLDO6HFXULW\&DUG
C
E
%LUWK&HUWLILFDWH
• /HDUQHU3HUPLW 0HGLFDO&HUWLILFDWH&'/2QO\ &UHGLW&DUG
863DVVSRUW
/LFHQVH3HUPLW 09 ,PDJH5HWULHYDO $70&DUG
6XUUHQGHUHGIRU 2IILFH
U )RUHLJQ3DVVSRUW
1RQ'ULYHU,'&DUG 2XWRI6WDWH/LFHQVH
S
2WKHU
E
 09('/ PAGE 2 OF 3
DRIVER LICENSE and LEARNER PERMIT APPLICANTS ONLY
 +DV\RXUGULYHUOLFHQVHOHDUQHUSHUPLWRUSULYLOHJHWRGULYHDPRWRUYHKLFOHEHHQVXVSHQGHGUHYRNHGRUFDQFHOOHGRUKDV\RXUDSSOLFDWLRQIRUDOLFHQVHEHHQ
GHQLHGLQWKLVVWDWHRUHOVHZKHUHLQWKHQDPH\RXSURYLGHRQWKLVIRUPRUDQ\RWKHUQDPH" <HV 1R
,I³<HV´KDV\RXUOLFHQVHSHUPLWRUSULYLOHJHEHHQUHVWRUHGRUKDV\RXUDSSOLFDWLRQEHHQDSSURYHG" <HV 1R
 +DYH\RXUHFHLYHGWUHDWPHQWGR\RXFXUUHQWO\UHFHLYHWUHDWPHQWRUGR\RXWDNHPHGLFDWLRQIRUDQ\FRQGLWLRQWKDWFDXVHVXQFRQVFLRXVQHVVRUXQDZDUHQHVV
IRUH[DPSOHDFRQYXOVLYHGLVRUGHUHSLOHSV\IDLQWLQJRUGL]]LQHVVRUDKHDUWFRQGLWLRQ" <HV 1R
If you marked “Yes”, you must submit form MV-80U.1, even if you were released from the Medical Review Program. You can get this form at any Motor
Vehicles office or at dmv.ny.gov.
 'R\RXQHHGDKHDULQJDLGDQGRUIXOOYLHZPLUURUWRGULYHDPRWRUYHKLFOH" <HV 1R
 +DYH\RXORVWWKHXVHRIDOHJDUPKDQGRUH\H" <HV 1R
D,I\RXQHHGWRUHQHZ\RXUGULYHUOLFHQVHDQG\RXPDUNHG³<HV´GLGWKLVRFFXUVLQFH\RXUODVWGULYHUOLFHQVH" <HV 1R
E,I\RXPDUNHG³12´WRDKDV\RXUFRQGLWLRQJRWWHQZRUVHVLQFH\RXUODVWGULYHUOLFHQVH" <HV 1R

PARENT/GUARDIAN CONSENT -XQLRU/LFHQVH 1RQGULYHU,'&DUGunder 16 )

, DP WKH SDUHQW RU JXDUGLDQ RI WKH DSSOLFDQW DQG , FRQVHQW WR WKH LVVXDQFH RI D OHDUQHU SHUPLW OLFHQVH RU LI XQGHU  D QRQGULYHU ,' FDUG WR KLPKHU ,
XQGHUVWDQGWKDW,DPUHVSRQVLEOHIRUFHUWLI\LQJWKDWWKHDSSOLFDQWKDVFRPSOHWHGDWOHDVWKRXUVRIVXSHUYLVHG³SUDFWLFH´GULYLQJLQFOXGLQJKRXUVRIGULYLQJ
DIWHUVXQVHWSULRUWRWKHDSSOLFDQWWDNLQJDURDGWHVWDQGWKDWWKLVFHUWLILFDWLRQ09PXVWEHSUHVHQWHGDWWKHWLPHRIWKHURDGWHVW1RWHWRSDUHQWJXDUGLDQ
If the driver license applicant is 17 years old and has a Driver Education Student Certificate of Completion (MV-285), consent is not required.
3DUHQWRU*XDUGLDQ
6LJQ+HUH t
5HODWLRQVKLSWR$SSOLFDQW 'DWH
Teen Electronic Event Notification Service (TEENS)
,ZRXOGOLNHWRHQUROOLQWKH7((16SURJUDPWREHQRWLILHGLIWKHXQGHU\HDUROGDSSOLFDQW ID Number on NYS Driver License, Permit or Non-driver ID
UHFHLYHVDFRQYLFWLRQVXVSHQVLRQUHYRFDWLRQRUDQDFFLGHQWRQWKHLUOLFHQVHILOH)RUPRUH Card of Consenting Parent or Guardian Above (Required)
LQIRUPDWLRQDERXWWKLVSURJUDPVHHIRUP09+RZWR(QUROOLQ7((16RU09
7((16)$4V7KLVLVDFREE VHUYLFH

COMMERCIAL DRIVER LICENSE APPLICANTS ONLY

1. In the past 10 years, was a driver license issued to you from another state in the U.S. or the District of Columbia ? <HV 1R
If YES, write the name of each one (if you turn in a license from another state, do not include that state):

2. You MUST certify to DMV that you operate (or expect to operate) a commercial motor vehicle in one of the following four driving types (select only one):
Non-excepted Interstate (NI) - &HUWLILHGPHGLFDOVWDWXVLVUHTXLUHG<RXDUHDJHRUROGHUDQG\RXRSHUDWHRUH[SHFWWRRSHUDWHLQWHUVWDWHRWKHUWKDQ
IRUH[FHSWHGRSHUDWLRQ
Non-excepted Intrastate (NA) - &HUWLILHGPHGLFDOVWDWXVLVUHTXLUHG<RXDUHDJHRUROGHUDQG\RXRSHUDWHRUH[SHFWWRRSHUDWHLQ1<6RQO\RWKHU
WKDQIRUH[FHSWHGRSHUDWLRQ
Excepted Interstate (EI) -<RXDUHDJHRUROGHUDQG\RXRSHUDWHRUH[SHFWWRRSHUDWHLQWHUVWDWHLQ([FHSWHG2SHUDWLRQ21/<<RXPXVWKDYH$UHVWULFWLRQ
Excepted Intrastate (EA) - <RXDUHDJHRUROGHUDQG\RXRSHUDWHRUH[SHFWWRRSHUDWHLQ([FHSWHG2SHUDWLRQ21/<DQGLQ1<621/<<RXPXVWKDYH$
DQG.UHVWULFWLRQV
If the driving type you selected requires certified medical status (NI or NA) you must provide a legible copy of your current USDOT Medical Examiner’s
Certificate to DMV if it is not already on file. Please see DMV form MV-44.5 if additional information is needed to help you determine your driving type.

CERTIFICATION , FHUWLI\ WKDW WKH LQIRUPDWLRQ , KDYH JLYHQ RQ WKLV DSSOLFDWLRQ LV WUXH DQG FRPSOHWH , XQGHUVWDQG WKDW WKH LQIRUPDWLRQ SURYLGHG ZLWK WKLV
DSSOLFDWLRQZLOOEHXVHGWRYHULI\P\LGHQWLW\UHVLGHQF\86FLWL]HQVKLSRUODZIXOSUHVHQFHLQWKH86,DPDSSO\LQJIRURQHRUPRUHRIWKHIROORZLQJ
Ɣ Enhanced Driver License ,DPD86FLWL]HQDQGDUHVLGHQWRI1<6
Ɣ REAL ID Document ,DPODZIXOO\SUHVHQWLQWKH86
Ɣ Replacement Driver License/Non-driver I.D. 0\1<6GULYHUOLFHQVHRUQRQGULYHU,'KDVEHHQORVWVWROHQRUPXWLODWHG,I,ILQGWKHORVWGRFXPHQW
DIWHU'09LVVXHVDUHSODFHPHQWWRPH,ZLOOUHWXUQWKHIRXQGGRFXPHQWWR'09
Ɣ Exchanging Out-of-State Driver License for a NYS Driver License - :KHQ,REWDLQHGP\RXWRIVWDWHGULYHUOLFHQVH,ZDVDSHUPDQHQWUHVLGHQWRIWKHVWDWH
RUSURYLQFHWKDWLVVXHGWKHOLFHQVHand WKDWOLFHQVHKDVEHHQYDOLGIRUDWOHDVWPRQWKVand ,KDYHQRWIDLOHGDGULYLQJVNLOOVURDGWHVWLQ1<6LQWKHODVWPRQWKV
Selective Service ,I,DPDPDOHDWOHDVWEXWOHVVWKDQ\HDUVROG'09ZLOOSURYLGHWKLVLQIRUPDWLRQIRUUHJLVWUDWLRQZLWKWKH866HOHFWLYH6HUYLFH6\VWHP
IMPORTANT: Making a false statement in any license or non-driver ID card application, or in any proof or statement in connection with it, or
deceiving or substituting, or causing another person to deceive or substitute in connection with such application, may subject you to criminal
prosecution for a misdemeanor or felony under the Vehicle and Traffic Law and/or the Penal Law.

t
SIGN HERE DATE:

PLEASE PRINT NAME t Sharad Suresh Shivmath // /

CREDIT CARD AUTHORIZATION IF CARDHOLDER IS NOT THE APPLICANT:
0\VLJQDWXUHDXWKRUL]HVBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Sign
WR XVH P\ FUHGLW FDUG IRU SD\PHQW RI DQ\ IHHV LQ FRQQHFWLRQ ZLWK WKLV DSSOLFDWLRQ Here t
DQG,XQGHUVWDQGWKDW,௖PXVWEHSUHVHQWIRUWKLVWUDQVDFWLRQ &DUGKROGHU6LJQ1DPHLQ)XOO
O 7(675(68/76 $SSOLFDQW¶V6LJQDWXUH ([DPLQHU¶V,QLWLDOV
F
U
F
S (\H 3DVV &RUUHFWLYH/HQV 
I
E
C
E
:ULWWHQ 3DVV )DLO 
09('/ PAGE 3 OF 3
NEW YORK STATE VOTER REGISTRATION APPLICATION INFORMATION 2)),&(86(௖21/<
(Please read before you complete application on the other side.)

Use the NYS Voter Registration Application to Register to Vote in NYS Elections, and/or:
change the name or address on your voter registration become a member of a political party change your party membership
To Register You Must:
be a U.S. citizen; be 18 years old by the end of this year; not be in prison or on parole for a felony conviction; not claim the right to vote elsewhere
Información en español: si le interse obtener
,QIRUPDFLyQHQHVSDxROVLOHLQWHUVHREWHQHU
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[
este formulario de re-gistro del votante en
HVWHIRUPXODULRGHUHJLVWURGHOYRWDQWHHQ
español, llame al 1-800-367-8683
HVSDxROOODPHDO xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[

西班牙语信息：如果您有兴趣获得西班牙语的这
语信息：如果您有兴趣获得西班牙语的这
스페인어로 된 정보 :이 유권자 등록 양식을 스페인
스페인어로된정보이유권자등록양식을스페인 西班牙
어로 얻으려면 1-800-367-8683으로 전화하십시오. 种选民登记表，请致电
어로얻으려면으로전화하십시오 种选民登记表，请致电1-800-367-8683
If you do not complete the NYS Voter Registration Application, you will be considered to have declined to register to vote. If you decline to register to vote,
the fact that you have declined to register will remain confidential and will be used only for voter registration purposes. If you do register to vote, the office at
which you submit a voter registration application will remain confidential and will only be used for voter registration purposes. If you believe that someone
has interfered with your right to register or decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or
your right to choose your own political party or other political preference, you may file a complaint with the NYS Board of Elections, 40 Steuben Street,
Albany, NY 12207-2109 (phone: 1-800-469-6872).
Your completed application will be sent to the Board of Elections and you will be notified by your County Board of Elections when your application has been
processed. If you have any questions about filling out the voter registration application or registering to vote, you should call your County Board of Elections
or call 1-800-FOR-VOTE (TDD/TTY dial 711) (only for voter registration questions). If you live in New York City, you should call 1-866-VOTE-NYC. You
may also find answers or tools at the NYS Board of Elections website: www.elections.ny.gov

NEW YORK STATE VOTER REGISTRATION APPLICATION

2QO\ ILOOWKLVRXWLI\RXZDQWWRUHJLVWHUWRYRWHRUFKDQJH\RXUDGGUHVVRURWKHULQIRUPDWLRQZLWKWKH%RDUGRI(OHFWLRQV
,I \RX UHJLVWHU WR YRWH \RXU FRPSOHWHG YRWHU UHJLVWUDWLRQ DSSOLFDWLRQ ZLOO EH VHQW GLUHFWO\ WR WKH %RDUG RI (OHFWLRQV ,I \RX GHFOLQH WR UHJLVWHU \RXU GHFLVLRQ ZLOO
UHPDLQFRQILGHQWLDO<RXZLOOEHQRWLILHGE\\RXU&RXQW\%RDUGRI(OHFWLRQVZKHQ\RXUYRWHUUHJLVWUDWLRQDSSOLFDWLRQKDVEHHQSURFHVVHG
$UH\RXDFLWL]HQRIWKH86" <HV 1R :LOO\RXEH\HDUVRIDJHRUROGHURQRUEHIRUHHOHFWLRQGD\" <HV 1R 7HOHSKRQH1XPEHURSWLRQDO
If you answer NO, you cannot register to vote If you answer NO, you cannot register to vote unless you will be 18 by the end of the year.
+DYH\RXYRWHGEHIRUH" 9RWLQJLQIRUPDWLRQWKDW <RXUQDPHZDV <RXUVWDWHRU1<6
<HV 1R KDVFKDQJHG &RXQW\ZDV
:KDW<HDU" VNLSLIWKLVKDVQRWFKDQJHGRU <RXUDGGUHVVZDV
\RXKDYHQRWYRWHGEHIRUH

Political Party I wish to enroll in a political party: AFFIDAVIT: ,VZHDURUDIILUPWKDW

<RX PXVW PDNH 
VHOHFWLRQ 3ROLWLFDO SDUW\
HQUROOPHQW LV RSWLRQDO
EXW WKDW LQ RUGHU WR YRWH
LQ D SULPDU\ HOHFWLRQ RI D
SROLWLFDO SDUW\ D YRWHU
PXVW HQUROO LQ WKDW
SROLWLFDO SDUW\ XQOHVV
VWDWH SDUW\ UXOHV DOORZ
RWKHUZLVH
I do not wish to enroll in a political party
'HPRFUDWLFSDUW\ ,DPDFLWL]HQRIWKH8QLWHG6WDWHV
5HSXEOLFDQSDUW\ ,ZLOOKDYHOLYHGLQWKHFRXQW\FLW\RUYLOODJHIRUDWOHDVWGD\VEHIRUHWKHHOHFWLRQ
&RQVHUYDWLYHSDUW\ ,PHHWDOOUHTXLUHPHQWVWRUHJLVWHUWRYRWHLQ1HZ<RUN6WDWH
*UHHQSDUW\ 7KLVLVP\VLJQDWXUHRUPDUNRQWKHOLQHEHORZ
:RUNLQJ)DPLOLHVSDUW\ 7KHDERYHLQIRUPDWLRQLVWUXH,XQGHUVWDQGWKDWLILWLVQRWWUXH,FDQEHFRQYLFWHGDQGILQHGXSWRDQGRU
,QGHSHQGHQFHSDUW\ MDLOHGIRUXSWRIRXU\HDUV.
:RPHQ¶V(TXDOLW\SDUW\
5HIRUPSDUW\
2WKHUBBBBBBBBBBBBBBBBB
09('/ 1RSDUW\ 6LJQ ; 'DWH

reset/clear