PENNSYLVANIA VOTER REGISTRATION

REGISTER •
To Register You Must:
MAIL APPLICATION

AND •
Be a citizen of the United States for at least one month before the next election;
Be a resident of Pennsylvania and your election district for at least 30 days

VOTE •
before the next election; and
Be at least 18 years of age on the day of the next election.

www.VotesPA.com GENERAL INSTRUCTIONS

1. Please provide all information on the application as required. Read all instructions carefully before you
fill out the application.
2. If you are currently registered, you do not need to re-register unless you have moved or changed your
name since you last registered.
3. In order to vote in the next election, this application must be received by your county voter registration
office no later than 30 days before the election, or postmarked no later than the thirtieth day before the
election. Military electors may apply at any time. For more information on military and overseas
electors, see www.fvap.gov.
4. Write the mailing address for your county voter registration office on the reverse side of this
application and place the proper postage in the designated area. Addresses for all Pennsylvania
counties are listed on the back of this form.
5. You are not registered to vote until your application has been processed and accepted by the county
voter registration office. If accepted, the county voter registration office will send you, via
nonforwardable mail, a Voter Identification Card. If you do not receive a Voter Identification Card
within 14 days of the date you submit this application, contact your county voter registration office.
6. If you decline to register to vote, your decision will remain confidential. If you register to vote, the
office at which you register will remain confidential and be used for voter registration purposes only.
7. Do not use staples or duct tape.
8. Print and sign clearly in blue or black pen.

3b Pennyslvania Driver’s License OR Social Security Number: You
must supply a PA Driver’s License Number if you have one. If you do
not have a PA Driver’s License Number, you must supply the last four
digits of your Social Security Number. If you do not have a Social
Security Number, please check the box to the right of 3b.
4a Address of Residence: Fill in your complete address of residence.
P.O. boxes may not be used here unless there is no physical address.
Print street address, city and zip code. (If the residence is only a portion
of the house, include the location of the room, apartment or
floor which is occupied.) 4b Although providing your telephone
number is optional, it is a quick and easy way for your county to
contact you if there is missing information on your registration form.
In Box 4c fill in the name of the municipality (city, borough or
township) and county where you live. Use the map in the box below if
you cannot otherwise identify your address.
Prior Registration: If you were registered before, fill in the name used
on your previous registration in Box 8a and address, county and year of
previous registration in Box 8b.
Name of Assistant: If the applicant is unable to complete or sign the
application, the person who assisted the applicant must provide his or her
name, address and signature.
Registration Declaration: You must be a citizen of the United States to
register to vote in the Commonwealth of Pennsylvania. Please read the
registration declaration carefully. You must sign and print your name and
date the application.
If you were assigned a Voter Identification Number, which appears on
your Voter Identification Card, place that Identification Number, if
available here. If you are applying to register to vote for the first time,
leave this box blank.

If you require assistance when voting, you must check the box and provide
the reason.

PENALTY FOR FALSIFYING REGISTRATION DECLARATION

WARNING: If a person signs an official registration application knowing a
statement declared in the application to be false, makes a false
registration, or furnishes false information, the person commits perjury.
Perjury is punishable, upon conviction, by a term of imprisonment not
exceeding seven years, or a fine not exceeding $15,000, or both, at the
discretion of the court. Submitting an application containing false
information may also subject a person to other penalties, including loss of
the right of suffrage, under state or federal law.
 PENNSYLVANIA VOTER REGISTRATION APPLICATION
Are you a citizen of the United States of America? Yes No If you checked “No” in response to either of
1
Will you be 18 years of age on or before election day? Yes No } these questions, do not complete this form.
2
I am a Federal or State employee and wish to retain my voting
New Registration Change of Name Change of Address Change of Party
residence in the county where I last resided.

3 M Last Name First Name Middle Name/Initial Jr Sr II III IV

a F (circle if applicable)

3 Place PA Driver’s
License (DL) # here
If no PA DL #, Place
SS# (last 4 digits) here:
I DO NOT have a PA Driver’s License
or Social Security Number.
b if you have one:

4 Address of residence, include street and city (Use map above if no street number or name) (If only P.O. box, see above) Apt # State Zip Code
4 Telephone Number (Optional)

a PA b ( )
4 Municipality where you live County where you live
5 Mailing Address (if different than address of residence) City State Zip Code

c
6 Date of Birth 7 Race (Optional) 8 Name on previous registration Address of previous registration (include street and city)

/ / a 8
party do you wish to register? You must register with a party if you want to take part in that party’s primary. b County of previous registration Year of previous registration
9 In which
Democratic Republican Libertarian No affiliation Other
Name and signature of person who assisted in the completion of this application Place signatue with full name (or mark) below
10 Address (Please see Penalty for Falsifying Declaration.)

11 I(1)HEREBY DECLARE THAT:

On the day of the next election I will have been a United States citizen

X
for at least one month. I will be at least 18 years of age, and I will have
resided in Pennsylvania and in my election district for at least 30 days;
(2) I am legally qualified to vote.
AND I HEREBY AFFIRM THAT the information I have provided in this
Print Your Name Below Date:
registration declaration is true. I understand that this registration declaration will
be accepted for all purposes as the equivalent of an affidavit; and if the registration
contains a materially false statement, I will be subject to penalties for perjury. / /
Voter Identification Number
12 (Ifor ifavailable - not necessary if you are registering to vote for the first time
you do not know your number.)

13 Do you require assistance

when voting? Yes No
Reason for assistance:

• For more information on voting, please visit our educational web site: www.VotesPA.com.
• hotline
If you do not receive your voter ID card in the mail within two weeks, call your county voter registration
1-800-552-VOTE.
or our toll-free

• Ifvoter
you are interested in becoming a poll worker or a bilingual interpreter on Election Day, please check the boxes. Your
registration will contact you.
county

I would like to be a poll worker on Election Day

I would like to be a bilingual interpreter on Election Day
Specify Language:

• Although providing your e-mail address is optional, it is a quick and easy way for your county voter registration
you in case there is missing information on your registration form:
to contact

IDENTIFICATION WHEN YOU VOTE

residence.) DSBE-600 2/09

 ADDRESSES OF COUNTY VOTER REGISTRATION OFFICES
To mail this application, write the address of the County Voter Registration Office in the proper area on the reverse side of this form.

ADAMS COUNTY COLUMBIA COUNTY LEBANON COUNTY SCHUYLKILL COUNTY

111-117 BALTIMORE ST 35 W MAIN ST PO BOX 380 400 S 8TH ST 420 N C E NT R E S T
GETTYSBURG PA 17325-2312 BLOOMSBURG PA 17815-0380 LEBANON PA 17042-6794 POTTSVILLE PA 17901
(570) 389-5640 (717) 274-2801 EXT 4428 (570) 628-1467
(717) 337-9832
LEHIGH COUNTY SNYDER COUNTY
ALLEGHENY COUNTY CRAWFORD COUNTY PO BOX 217
542 FORBES ST STE 609 903 DIAMOND PARK 17 S 7TH ST MIDDLEBURG PA 17842-0217
P IT T S B U R G H PA 15219-29 13 MEADVILLE PA 16335-2678 ALLENTOWN PA 18101-2401 (570) 837-4209
(412) 350-4500 (814) 333-7306 (610) 782-3194
SOMERSET COUNTY
ARMSTRONG COUNTY CUMBERLAND COUNTY LUZERNE COUNTY 300 N CENTER AVE STE 340
450 E. MARKET ST, STE 207 310 ALLEN RD 20 N PENNSYLVANIA AVE STE 207 SOMERSET PA 15501
KITTANNING PA 16201 CARLISLE PA 17013-3044 WILKES-BARRE PA 18701-3505 (814) 445-1549
(570) 825-1715
(724) 548-3222 (717) 240-6385
LYCOMING COUNTY UNION COUNTY
BEAVER COUNTY DAUPHIN COUNTY 48 W THIRD ST 155 N 15TH ST
810 THIRD ST PO BOX 1295 WILLIAMSPORT PA 17701-0536 LEWISBURG PA 17837-8822
BEAVER PA 15009 HARRISBURG PA 17108-1295 (570) 327-2267 (570) 524-8681
(724) 728-5700 (717) 780-6360
MCKEAN COUNTY VENANGO COUNTY
BEDFORD COUNTY DELAWARE COUNTY 500 W MAIN ST COURTHOUSE 1174 ELK ST PO BOX 831
200 SOUTH JULIANA ST 3RD FLOOR GOVT CENTER BLDG 201 W FRONT ST SMETHPORT PA 16749 FRANKLIN PA 16323-0831
BEDFORD PA 15522 MEDIA PA 19063-2728 (814) 887-3203
(814) 432-9514
(814) 623-4807 (610) 891-4659 MERCER COUNTY
5 COURTHOUSE WARREN COUNTY
BERKS COUNTY ELK COUNTY MERCER PA 16137-1227 204 4TH AVE
633 COURT ST 300 CENTER ST PO BOX 448 (724) 662-3800 EXT 2240 WARREN PA 16365-2399
READING PA 19601 RIDGWAY PA 15853-0448 (814) 728-3406
(610) 478-6490 (814) 776-5337 MIFFLIN COUNTY
20 N WAYNE ST WASHINGTON COUNTY
BLAIR COUNTY ERIE COUNTY LEWISTOWN PA 17044 100 W BEAU ST RM 206
423 ALLEGHENY ST STE 043 140 W 6TH ST RM 105 (717) 248-6571 WASHINGTON PA 15301
HOLLIDAYSBURG PA 16648-2022 ERIE PA 16501-1096 (724) 228-6750
(814) 693-3150 (814) 451-6276 MONROE COUNTY
ONE QUAKER PLAZA RM 105 WAYNE COUNTY
BRADFORD COUNTY FAYETTE COUNTY STROUDSBURG PA 18360-2170 925 COURT ST
301 MAIN ST 22 E MAIN ST PUBLIC SERVICE BLDG (570) 517-3165 HONESDALE PA 18431-1996
TOWANDA PA 18848-1878 UNIONTOWN PA 15401 (570) 253-5978
(570) 265-1717 (724) 430-1289 MONTGOMERY COUNTY
COURTHOUSE PO BOX 311 WESTMORELAND COUNTY
BUCKS COUNTY FOREST COUNTY NORRISTOWN PA 19404-0311 2 N MAIN ST STE 109
55 E COURT ST 526 ELM ST BOX 3 (610) 278-3280 GREENSBURG PA 15601
DOYLESTOWN PA 18901-4318 TIONESTA PA 16353 (724) 830-3150
(215) 348-6163 (814) 755-3537 MONTOUR COUNTY
29 MILL ST WYOMING COUNTY
FRANKLIN COUNTY 1 COURTHOUSE SQ
157 LINCOLN WAY EAST DANVILLE PA 17821
BUTLER COUNTY (570) 271-3000 TUNKHANNOCK PA 18657-1216
PO BOX 1208 CHAMBERSBURG PA 17201-2211
(717) 261-3886 (570) 996-2226
BUTLER PA 16003-1208 NORTHAMPTON COUNTY
(724) 284-5308 670 WOLF AVE YORK COUNTY
FULTON COUNTY E A S T O N PA 18042- 4343 28 EAST MARKET ST
116 W MARKET ST STE 203 (610) 559-3055 YORK PA 17401-1579
CAMBRIA COUNTY MCCONNELLSBURG PA 17233 (717) 771-9604
200 S CENTER ST (717) 485-3691 NORTHUMBERLAND COUNTY
EBENSBURG PA 15931 609 MARKET ST
(814) 472-1464 GREENE COUNTY SUNBURY PA 17801-2360
93 E HIGH ST RM 102 (570) 988-4208
WAYNESBURG PA 15370
CAMERON COUNTY (724) 852-5230 PERRY COUNTY
20 E FIFTH ST PO BOX 37
EMPORIUM PA 15834-1469 HUNTINGDON COUNTY NEW BLOOMFIELD PA 17068-0037
(814) 486-2315 223 PENN ST COURTHOUSE (717) 582-2131 EXT 4110
CARBON COUNTY HUNTINGDON PA 16652-1486
76 SUSQUEHANNA ST PO BOX 170 (814) 643-3091 PHILADELPHIA COUNTY
JIM THORPE PA 18229-0170 520 N DELAWARE AVE 5TH FL
INDIANA COUNTY PHILADELPHIA PA 19123-4295
(570) 325-4801
825 PHILADELPHIA ST (215) 686-1591
CENTRE COUNTY INDIANA PA 15701-3934
420 HOLMES ST (724) 465-3852 PIKE COUNTY
BELLEFONTE PA 16823-1488
(814) 355-6703 JEFFERSON COUNTY
506 BROAD ST
MILFORD PA 18337-1535
For a listing of available
CHESTER COUNTY
155 MAIN ST JEFFERSON PLACE
BROOKVILLE PA 15825-1269
(570) 296-3426 county e-mail addresses, go to:
601 WESTTOWN RD STE 150 (814) 849-1605 POTTER COUNTY www.VotesPA.com
PO BOX 2747 1 NORTH MAIN ST
WEST CHESTER PA 19380-0990 JUNIATA COUNTY COUDERSPORT PA 16915
(610) 344-6410 BRIDGE ST PO BOX 68 (814) 274-8467
MIFFLINTOWN PA 17059
(717) 436-7706 SULLIVAN COUNTY
CLARION COUNTY
PO BOX 157
421 MAIN ST STE 19 LACKAWANNA COUNTY LAPORTE PA 18626-0157
CLARION PA 16214-1093 135 JEFFERSON AVE STE 100 (570) 946-5201
(814) 226-4000 EXT 2205 SCRANTON PA 18503
(570) 963-6737 SUSQUEHANNA COUNTY
CLEARFIELD COUNTY PO BOX 218 MAPLE ST
230 E MARKET ST STE 108 LANCASTER COUNTY MONTROSE PA 18801-0218
CLEARFIELD PA 16830 150 NORTH QUEEN ST STE 102 (570) 278-4600 EXT 220
(814) 765-2641 EXT 5996 LANCASTER PA 17603-3562
(717) 299-8293 TIOGA COUNTY
118 MAIN ST
CLINTON COUNTY LAWRENCE COUNTY WELLSBORO PA 16901-0589
232 E MAIN ST GARDEN BLDG 3RD FL 430 COURT ST (570) 723-8230
LOCK HAVEN PA 17745-1385 NEW CASTLE PA 16101-3593
(570) 893-4019 (724) 656-2161