Voter Registration Application

Before completing this form, review the General, Application, and State speci!c instructions. Are you a citizen of the United States of America? Yes No 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-speci!c instructions for rules regarding eligibility to register prior to age 18.) This space for o"ce use only.

1

Mr.

Mrs.

Miss

Ms.

Last Name First Name Middle Name(s) Jr

Sr

II

III

IV

2

Home Address Apt. or Lot # City/Town State Zip Code 3

Address Where You Get Your Mail If Di#erent From Above City/Town State Zip Code 4

Date of Birth

Month Day Year

5

Telephone Number (optional)

6

ID Number - (See item 6 in the instructions for your state) 7

Choice of Party

(see item 7 in the instructions for your State) 8

Race or Ethnic Group

(see item 8 in the instructions for your State)

Q

Q

Q

O

O

Q

Q

9 Q

I have reviewed my state's instructions and I swear/a"rm that: I am a United States citizen

I meet the elig ibility requirements of my state and subscribe to any oath required.

The information I have provided is true to the best of my knowledge under penalty of perjury. If I have provided false information, I may be !ned, imprisoned, or (if not a U.S. citizen) deported from or refused entry to the United States. Please sign full name (or put mark)

Date:

Month Day Year

If you are registering to vote for the !rst time: please refer to the application instructions for information on submitting copies of valid identi!cation documents with this form. Please !ll 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? A

Mr.

Mrs.

Miss

Ms.

Last Name First Name Middle Name(s) Jr

Sr

II

III

IV

If you were registered before but this is the !rst time you are registering from the address in Box 2, what was your address where you were registered before? B

Street (or route and box number) Apt. or Lot # City/Town/County State Zip Code 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. C

Write in the names of the crossroads (or streets) nearest to where you live. 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

Woodchuck Road

Route #2

Public School

Grocery Store

X

NORTH

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

Mail this application to the address provided for your State. 4

4

Martin Jeffrey Todd

4537 Lake Grove Ln Dallas TX 75211

07-19-1952

832-***-****

Republican

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