North Carolina Voter Registration Application 15

DMV Agency Form

Qualifications to register to vote: Please note:

• You must be a U.S. citizen by birth or naturalization. The location where you received this
• You must register to vote only in the county in where you live. form will remain confidential and will
• You must be at least 18 years old by general election day OR you may preregister if you are at least 16 be used only for voter registration
years old and understand that you must be 18 years of age on or before election day to vote. purposes. If you choose not to register
• You must not be currently serving a felony sentence, including any probation, post-release supervision, or to vote, your choice not to register will
parole OR you are serving an extended term of probation, post-release supervision, parole, you have also remain confidential.
outstanding fines, fees, or restitution, and you do not know of another reason that your probation, post-
release supervision, or parole was extended. No special document is required.

1 Your Qualifications to Vote

Check the appropriate box next to each question

Are you a citizen of the United States of America?

Note: If you checked “No” in response to this question, DO NOT submit this form. U.S. citizenship is required to vote. Yes No

Will you be at least 18 years of age on or before election day? Yes No

Are you at least 16 years of age and understand that you must be 18 years of age on or before election day to vote? Yes No
Note: If you checked “No” in response to both questions, DO NOT submit this form. You must be at least 18 years old to register to vote or at least 16 years old to preregister to vote.

2 Your Name 3 Your date of birth and identification information

Legal Last Name Date of Birth (MM/DD/YYYY) State or Country of Birth

ALLEN 07/16/1949
Legal First Name NC Driver License or NC DMV ID Number Last Four Digits of Social Security Number

DONALD
Middle Name Suffix 000002464305 4714
JOSEPH
4 Your Residential Address - where you physically live 5 Your Mailing Address (optional) – where you receive mail
DO NOT enter a P.O. Box or a mail drop location. If you do not receive mail where you live, please provide a mailing address.
Residential Address Mailing Address

2601 SPRING VALLEY TER 2601 SPRING VALLEY TER

SHELBY, NC, 28152-9076 SHELBY, NC, , 281529076

County of Residence
CLEVELAND
6 Your Demographic Information and Party Affiliation (optional)
If you do not indicate a party affiliation, you will be registered as an unaffiliated voter.
Gender Race Ethnicity Party Affiliation

7 Your Previous Voter Registration Address (optional)

Please complete this section if you are currently registered to vote in another county or state.
Name Used in Last Registration

Address Where You Were Last Registered County or State of Last Registration

8 Your Contact Information (optional)

This information may be used to contact you concerning your voter registration. This information may be disclosed as a public record.

Phone Number

9 Your Attestation and Signature

I am declining voter registration services. I do not wish to register or preregister to vote at this time. I understand that
the fact I declined these services will remain confidential, except for administrative purposes related to voter
registration.

FRAUDULENTLY OR FALSELY COMPLETING THIS FORM IS A CLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES.

2022.07.10 19.59.38
Signature Date
NCSBOE 2020.09