Fold on line and seal before mailing

For Assistance
Call your local Voter Registrar or
2IFHRIWKH6HFUHWDU\RI6WDWH
Toll Free: Si necesita asistencia
llame gratis al:
1-800-252-VOTE(8683)
www.sos.state.tx.us

REGISTRAR OF VOTERS
COUNTY COURTHOUSE
(CITY)

(ZIP CODE)

_____________________ , TX _______________

Fold on line and seal before mailing

4XDOLFDWLRQV
 <RX PXVW UHJLVWHU WR YRWH LQ WKH FRXQW\ LQ ZKLFK \RX
reside.
 <RXPXVWEHDFLWL]HQRIWKH8QLWHG6WDWHV
 <RX PXVW EH DW OHDVW  \HDUV DQG  PRQWKV ROG WR
UHJLVWHUDQG\RXPXVWEH\HDUVRIDJHE\HOHFWLRQ
day.
 <RXPXVWQRWEHQDOO\FRQYLFWHGRIDIHORQ\RULI\RXDUH
 



DIHORQ\RXPXVWKDYHFRPSOHWHGDOORI\RXUSXQLVKPHQW





  

LQFOXGLQJDQ\WHUPRILQFDUFHUDWLRQSDUROHVXSHUYLVLRQ
SHULRGRISUREDWLRQRU\RXPXVWKDYHUHFHLYHGDSDUdon.
 <RXPXVWQRWKDYHEHHQGHWHUPLQHGE\DQDOMXGJPHQW
RI D FRXUW H[HUFLVLQJ SUREDWH MXULVGLFWLRQ WR EH WRWDOO\
PHQWDOO\LQFDSDFLWDWHGRUSDUWLDOO\PHQWDOO\LQFDSDFLWDWHG

 


ZLWKRXWWKHULJKWWRYRWH

Este formulario est disponible en Espaol.

)DYRUGHOODPDUVLQFDUJRDODRFLQDGHO6HFUHWDULRGH
Estado al 1-800-252-8683 para conseguir una version
en Espaol.

VR17.09EI3.indd 1

General Information
 <RXU YRWHU UHJLVWUDWLRQ ZLOO EHFRPH HIIHFWLYH 
GD\VDIWHULWLVUHFHLYHGRURQ\RXUWKELUWKGD\
ZKLFKHYHULVODWHU<RXUUHJLVWUDWLRQPXVWEHHIIHF
WLYHRQRUEHIRUHDQHOHFWLRQGD\LQRUGHUWRYRWHLQ
WKDWHOHFWLRQ
 ,I\RXPRYHWRDQRWKHUFRXQW\\RXPXVWUHUHJLVWHU


 




LQWKHFRXQW\RI\RXUQHZUHVLGHQFH
 <RX PXVW SURYLGH \RXU 7H[DV GULYHU
V OLFHQVH RU
SHUVRQDOLGHQWLFDWLRQQXPEHU,I\RXGRQRWKDYH
DGULYHU
VOLFHQVHRUSHUVRQDOLGHQWLFDWLRQQXPEHU


 


JLYHWKHODVWIRXUGLJLWVRI\RXUVRFLDOVHFXULW\QXP

EHU,I\RXGRQRWKDYHDQ\RIWKHVHLGHQWLFDWLRQ
QXPEHUVWKHQFKHFNWKHDSSURSULDWHER[RQWKH
DSSOLFDWLRQVLGH
 ,I\RXKDYHQRWEHHQLVVXHGDQ\RIWKHLGHQWLFDWLRQ


 


  
QXPEHUVDVGHVFULEHGDERYH\RXZLOOEHUHTXLUHG
WRSUHVHQWLGHQWLFDWLRQZKHQ\RXYRWHLQSHUVRQ
RUHQFORVHDFRS\RIVXFKLGHQWLFDWLRQZLWK\RXU
EDOORWLI\RXYRWHE\PDLO  ,GHQWLFDWLRQLQFOXGHV
DQ\SKRWR,'DFRS\RIDFXUUHQWXWLOLW\ELOOEDQN
VWDWHPHQWJRYHUQPHQWFKHFNSD\FKHFNRURWKHU
JRYHUQPHQWGRFXPHQWWKDWVKRZV\RXUQDPHDQG
address.

8/14/2009 10:12:25 AM

7H[DV9RWHU5HJLVWUDWLRQ$SSOLFDWLRQ
3UHVFULEHGE\WKH2IFHRIWKH6HFUHWDU\RI6WDWH

)RU2IFLDO8VH2QO\

95(,

3OHDVHFRPSOHWHVHFWLRQVE\SULQWLQJ/(*,%/<,I\RXKDYHDQ\TXHVWLRQVDERXWKRZWROORXWWKLVDSSOLFDWLRQ
SOHDVHFDOO\RXUORFDOYRWHUUHJLVWUDURUWKH6HFUHWDU\RI6WDWH
V2IFHWROOIUHHDW927(7''
ZZZVRVVWDWHW[XV

1 These Questions Must Be Completed Before Proceeding

Check one



1HZ$SSOLFDWLRQ &KDQJHRI$GGUHVV1DPH
RU2WKHU,QIRUPDWLRQ

$UH\RXD8QLWHG6WDWHV&LWL]HQ" 

5HTXHVWIRUD5HSODFHPHQW&DUG

 

:LOO\RXEH\HDUVRIDJHRQRUEHIRUHHOHFWLRQGD\"

Yes

No

Yes

No

,I\RXFKHFNHG
1R
LQUHVSRQVHWRHLWKHURIWKHDERYHGRQRWFRPSOHWHWKLVIRUP
$UH\RXLQWHUHVWHGLQVHUYLQJDVDQHOHFWLRQZRUNHU"

Yes

/DVW1DPH,QFOXGH6XI[LIDQ\

5HVLGHQFH$GGUHVV6WUHHW$GGUHVVDQG$SDUWPHQW1XPEHU,IQRQH

)LUVW1DPH

No

0LGGOH1DPH

)RUPHU1DPH(if any)

(If any)

(Jr, Sr, III)

GHVFULEHZKHUH\RXOLYH(Do not include P.O. Box, Rural Rt. or Business Address)

City

7(;$6
Zip Code

0DLOLQJ$GGUHVV6WUHHW$GGUHVVDQG$SDUWPHQW1XPEHU,IPDLO
FDQQRWEHGHOLYHUHGWR\RXUUHVLGHQFHDGGUHVV

City

6WDWH
Zip Code

'DWHRI%LUWK (mm/dd/yyyy)

Gender 2SWLRQDO
Male
Female

7HOHSKRQH1XPEHU 2SWLRQDO 


,QFOXGH$UHD&RGH

7H[DV'ULYHU
V/LFHQVH1RRU7H[DV3HUVRQDO ,IQR7H[DV'ULYHU
V/LFHQVHRU3HUVRQDO,GHQWLFDWLRQ
,'1R ,VVXHGE\WKH'HSDUWPHQWRI3XEOLF6DIHW\
JLYHODVWGLJLWVRI\RXU6RFLDO6HFXULW\1XPEHU

 
 




xxx-xx,KDYHQRWEHHQLVVXHGD7H[DV'ULYHU
V/LFHQVH3HUVRQDO,GHQWLFDWLRQ1XPEHURU
6RFLDO6HFXULW\1XPEHU

 I understand that giving false information to procure a voter registration is perjury, and a crime under

VWDWHDQGIHGHUDOODZ



&RQYLFWLRQRIWKLVFULPHPD\UHVXOWLQLPSULVRQPHQWXSWRGD\VDQHXSWR
 



 
  

 
 
$2,000, or both. Please read all threeVWDWHPHQWVWRDIUPEHIRUHVLJQLQJ
  
 


 

 ,DPDUHVLGHQWRIWKLVFRXQW\DQGD86FLWL]HQ

 


  
   


   
 ,KDYHQRWEHHQQDOO\FRQYLFWHGRIDIHORQ\RULIDIHORQ,KDYHFRPSOHWHGDOORIP\SXQLVKPHQW
including any term of incarceration, parole, supervision, period of probation, or I have been

SDUGRQHGDQG
 ,KDYHQRWEHHQGHWHUPLQHGE\DQDOMXGJPHQWRIDFRXUWH[HUFLVLQJSUREDWHMXULVGLFWLRQWR
be totally mentally incapacitated or partially mentally incapacitated without the right to vote.

'DWH

6LJQDWXUHRI$SSOLFDQWRU$JHQWDQG5HODWLRQVKLSWR$SSOLFDQWRU3ULQWHG1DPHRI$SSOLFDQWLI6LJQHGE\:LWQHVVDQG'DWH

VR17.09EI3.indd 2

8/14/2009 10:12:25 AM