F o l d o n l i n e a n d s e a l b e f o r e m a i l i n g

For Assistance
Call your local Voter Registrar or
Offce of the Secretary of State
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
Qualifcations
You must register to vote in the county in which you
reside.
You must be a citizen of the United States.
You must be at least 17 years and 10 months old to
register, and you must be 18 years of age by election
day.
You must not be fnally convicted of a felony, or if you are
a felon, you must have completed all of your punishment,
including any term of incarceration, parole, supervision,
period of probation, or you must have received a par-
don.
You must not have been determined by a fnal judgment
of a court exercising probate jurisdiction to be totally
mentally incapacitated or partially mentally incapacitated
without the right to vote.
General Information
Your voter registration will become effective 30
days after it is received or on your 18th birthday,
whichever is later. Your registration must be effec-
tive on or before an election day in order to vote in
that election.
f you move to another county, you must re-register
in the county of your new residence.
You must provide your Texas driver's license or
personal identifcation number. f you do not have
a driver's license or personal identifcation number,
give the last four digits of your social security num-
ber. f you do not have any of these identifcation
numbers, then check the appropriate box on the
application side.
f you have not been issued any of the identifcation
numbers as described above, you will be required
to present identifcation when you vote in person
or enclose a copy of such identifcation with your
ballot if you vote by mail. dentifcation includes:
any photo D; a copy of a current utility bill; bank
statement; government check; paycheck; or other
government document that shows your name and
address.
Este formul ari o est di sponi bl e en Espaol .
Favor de IIamar sin cargo a Ia ocina deI Secretario de
Estado al 1-800-252-8683 para conseguir una version
en Espaol.
VR17.09EI3.indd 1 8/14/2009 10:12:25 AM































Texas Voter Registration Application
Prescribed by the OIfce oI the Secretary oI State VR17.09E.I3
)RU2IFLDO8VH2QO\
Please complete sections by printing LEGBLY. f you have any questions about how to fll out this application,
please call your local voter registrar or the Secretary of State's Offce toll free at 1-800-252-VOTE(8683), TDD
1-800-735-2989, www.sos.state.tx.us.
1 These Questions Must Be Completed Before Proceeding
Check one
New Application Change of Address, Name,
or Other nformation
Request for a Replacement Card
Are you a United States Citizen? Yes No
WiII you be 18 years of age on or before eIection day? Yes No
If you checked 'No' in response to either of the above, do not compIete this form.
Are you interested in serving as an eIection worker? Yes No
2
Last Name nclude Suffx if any
(Jr, Sr, III)
First Name MiddIe Name
(If any)
Former Name (if any)
3
Residence Address: Street Address and Apartment Number. f none,
describe where you live. (Do not include P.O. Box, Rural Rt. or Business Address)
City
TEXAS
Zip Code
4
MaiIing Address: Street Address and Apartment Number. (f mail
cannot be delivered to your residence address.)
City State
Zip Code
5
Date of Birth: (mm/dd/yyyy)
6
Gender (Optional)
Male
Female
7
TeIephone Number (Optional)
IncIude Area Code
( )
8
Texas Driver's License No. or Texas PersonaI
I.D. No. (ssued by the Department of Public Safety)
If no Texas Driver's License or PersonaI Identication,
give Iast 4 digits of your SociaI Security Number
xxx-xx-
I have not been issued a Texas Driver's License/PersonaI Identication Number or
SociaI Security Number.
9 I understand that giving false information to procure a voter registration is perjury, and a crime under
state and federaI Iaw. Conviction of this crime may resuIt in imprisonment up to 180 days, a ne up to
$2,000, or both. Please read all three statements to afrm before signing.
I am a resident of this county and a U.S. citizen;
I have not been naIIy convicted of a feIony, or if a feIon, I have compIeted aII of my punishment
including any term of incarceration, parole, supervision, period of probation, or I have been
pardoned; and
I have not been determined by a naI judgment of a court exercising probate jurisdiction to
be totally mentally incapacitated or partially mentally incapacitated without the right to vote.
X
Date / /
Signature of AppIicant or Agent and ReIationship to AppIicant or Printed Name of AppIicant if Signed by Witness and Date.
VR17.09EI3.indd 2 8/14/2009 10:12:25 AM