Voter registration form

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INSTRUCTIONS FORMER FELONS

1. Print and complete this document. If you don’t
have a printer, your local library will print it for
you.
2. Sign and date the form. This is very important.
Some states make it difficult for formerly incarcerated
citizens to register to vote. Please visit our friends at
RestoreYourVote.org for help if you have ever been
convicted for a felony.
RestoreYourVote.org

3. Mail or hand-deliver the form to the address

listed below.
4. If you need a stamp, you can buy one at any
grocery store. Just ask the cashier.
DEADLINES
Your form must be postmarked 25 days before election day.
MILITARY AND OVERSEAS VOTERS
You can register to vote and get your absentee ballot
at the same time using the ​Federal Post Card
Application (FPCA). Our friends at the Overseas
Vote Foundation will help you prepare this form.
Please visit their site to get started:
https://www.overseasvotefoundation.org

ELECTION PROTECTION HOTLINE

MAILING ADDRESS
NYS Board of Elections If anyone is preventing you from voting, please call
the Election Protection Hotline for free and
40 North Pearl Street, Suite 5 nonpartisan advice:
Albany, NY 122072729
1-866-OUR-VOTE

QUESTIONS? NEED HELP

Contact your Local Election Office if you need help.
You’ll find contact information here:
https://www.usvotefoundation.org/vote/
eoddomestic.htm
 Voter Registration Application
Before completing this form, review the General, Application, and State specific instructions.

Are you a citizen of the United States of America? ✔ Yes No This space for office use only.
Will you be 18 years old on or before election day? ✔ Yes No
If you checked "No" in response to either of these questions, do not complete form.
(Please see state-specific instructions for rules regarding eligibility to register prior to age 18.)
✔ Mr. Miss Last Name First Name Middle Name(s) Jr II
1 Mrs. Ms. KUMAR
III
ANIL Sr IV
Home Address Apt. or Lot # City/Town State Zip Code
2 441 ARDSLEY ROAD SCARSDALE NY 10583
Address Where You Get Your Mail If Different From Above City/Town State Zip Code
3
Date of Birth Telephone Number (optional) ID Number - (See item 6 in the instructions for your state)
4 08/03/1962 5
Month Day Year 6
Choice of Party Race or Ethnic Group 469458962
(see item 7 in the instructions for your State) (see item 8 in the instructions for your State)
7 8
Democratic

I have reviewed my state's instructions and I swear/affirm that:

■ I am a United States citizen

■ I meet the eligibility requirements of my state and

subscribe to any oath required.
9 ■ The information I have provided is true to the best of my
Please sign full name (or put mark)
knowledge under penalty of perjury. If I have provided false
information, I may be fined, imprisoned, or (if not a U.S. Date:
citizen) deported from or refused entry to the United States.
Month Day Year

If you are registering to vote for the first time: please refer to the application instructions for information on submitting
copies of valid identification documents with this form.

Please fill out the sections below if they apply to you.

If this application is for a change of name, what was your name before you changed it?

Mr. Miss Last Name First Name Middle Name(s) Jr II

A Mrs. Ms. Sr
III
IV
If you were registered before but this is the first time you are registering from the address in Box 2, what was your address where you were registered before?

Street (or route and box number) Apt. or Lot # City/Town/County State Zip Code
B 28 Nassau Road 1 Yonkers NY 10710
If you live in a rural area but do not have a street number, or if you have no address, please show on the map where you live.
■ Write in the names of the crossroads (or streets) nearest to where you live. NORTH
■ Draw an X to show where you live.
■ Use a dot to show any schools, churches, stores, or other landmarks
near where you live, and write the name of the landmark.

Example
C
Route #2

● Grocery Store
Woodchuck Road
Public School ● X

If the applicant is unable to sign, who helped the applicant fill out this application? Give name, address and phone number (phone number optional).

Mail this application to the address provided for your State.

 FOR OFFICIAL USE ONLY

FIRST CLASS
STAMP
NECESSARY
FOR
MAILING

NYS Board of Elections

40 North Pearl Street, Suite 5

Albany, NY 122072729