Page 1 REGISTER Pennsylvania AND VOTE Voter Registration ...

1 Page 1. DSBE 02/2021. REGISTER . AND. Pennsylvania vote Voter Registration Application REGISTER to vote With this form, you can Send or deliver this form In the military? REGISTER to vote in elections To be registered in the next election, mail or If you are on active duty or you are a hospitalized in Pennsylvania . deliver your application form to your county or bedridden veteran, you can REGISTER at any Voter Registration office at least 15 days before time. See for more information. You can also use this form to: the next election. Change the information on your Addresses for all Pennsylvania counties are College student in Pennsylvania Voter Registration . listed on page 2. Pennsylvania ? REGISTER with a political party or change If your Registration is accepted, you will receive the party you have selected. a Voter Registration Card from your county by If you are a college student who attends college nonforwardable mail .

2 In Pennsylvania , you can REGISTER where you live If you are currently registered to vote in while attending school. Pennsylvania , you do not have to use this form Your Registration is not complete until unless you have moved or changed your name. processed and accepted by your county Voter For more information, see Registration office. You may only REGISTER and vote in one place. To REGISTER you must: If you do not receive your Voter Registration Be a United States citizen for at least 30 days Card within 7-10 days, contact your county In prison or convicted of a Voter Registration office. before the next election. felony? Be a resident of Pennsylvania and your election district for at least 30 days before Verifying your identity If you meet all other requirements, you may the next election. REGISTER and vote if: When you vote for the first time in your election Be at least 18 years of age on the day of the district, you must show a form of identification.

3 You are in prison awaiting trial but have not next election. been convicted. For a complete list of acceptable forms of photo You are in prison after being convicted of a and non-photo identification, visit misdemeanor only. or call your County Board of Elections or 1-877-VOTESPA You have been released from prison or a (1-877-868-3772). halfway house after completing your term of incarceration. REGISTER online You are on probation or released on parole. You can also REGISTER to vote You are under house arrest. on t he web. You should REGISTER at the address where you Go to live, except that you cannot use a prison or half-way house address for your Registration . See for more information. Questions? Call your County Voter For more information about Informaci n en espa ol: Registration Office voting, visit our website: Si le interesa obtener este formulario en espa ol, llame al 1-877-868-3772.

4 Or call 1-877-VOTESPA (1-877-868-3772). PENALTY FOR FALSIFYING DECLARATION Confidentiality Warning: If a person signs an official Registration application knowing a statement If you decline to REGISTER to vote , the fact that declared in the application to be false. makes a false Registration , or furnishes false you declined will remain confidential, and will information, the person commits perjury. be used for Voter Registration purposes only. Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven If you REGISTER to vote , the office at which you years. or a fine not exceeding $15,000, or both, at the discretion of the court. REGISTER will remain confidential and will be used for Voter Registration purposes only. 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.

5 Pennsylvania County Voter Registration Office addresses Page 2. PA-DOS VRAD Adams Chester Fulton Mercer Susquehanna 117 Baltimore St 601 Westtown Rd 116 W Market St 130 North Pitt Street,Ste B PO Box 218. Rm 106 Ste 150 Ste 205 Mercer PA 16137-1227 31 Lake Ave Gettysburg PA 17325 PO Box 2747 McConnellsburg PA 17233 (724) 662-7542 Montrose PA 18801. (717) 337-9832 West Chester PA 19380-0990 (717) 485-6872 (570) 278-6697. (610) 344-6410 Mifflin Allegheny Greene 20 N Wayne St Lewistown Tioga 542 Forbes Ave Clarion 93 E High St PA 17044 (717) 248-6571 118 Main St Ste 609 Administrative Building Rm 102 Wellsboro PA 16901. Pittsburgh PA 15219-2913 330 Main St Waynesburg PA 15370 Monroe (570) 723-8230. (412) 350-4500 Rm 104 (724) 852-5230 One Quaker Plaza Clarion PA 16214 Rm 105 Union Armstrong (814) 226-4000 Ext 2006 Huntingdon Stroudsburg PA 18360 155 N 15th St Administration Bldg Bailey Building (570) 517-3165 Lewisburg PA 17837-8822.

6 450 E Market St Clearfield 233 Penn St (570) 524-8681. Ste 207 212 E Locust St Huntingdon PA 16652-1486 Montgomery Kittanning PA 16201 Ste 106 (814) 643-3091 Ext 205 Voter Services Venango (724) 548-3222 Clearfield PA 16830 PO Box 311 1174 Elk St (814) 765-2642 ext 5053 Indiana Norristown PA PO Box 831. Beaver 825 Philadelphia St 19404-0311 (610) Franklin PA 16323-0831. 810 Third St Clinton Indiana PA 15701-3934 278-3280 (814) 432-9514. Beaver PA 15009 2 Piper Way (724) 465-3852. (724) 770-4440 Ste 309 Montour Warren Lock Haven PA 17745 Jefferson 435 East Front St., 204 4th Ave Bedford (570) 893-4019 155 Main St Danville PA 17821 Warren PA 16365. 200 S Juliana St Jefferson Place (570) 271-3002 (814) 728-3406. 3rd Fl Columbia Brookville PA 15825-1269. Ste 301 PO Box 380 (814) 849-1693 Northampton Elections Washington Bedford PA 15522 Bloomsburg PA 17815-0380 Division 100 W Beau St (814) 623-4807 (570) 389-5640 Juniata 669 Washington St Rm 206.

7 1 N Main St Easton PA 18042 Washington PA 15301. Berks Crawford PO Box 68 (610) 829-6260 (724) 228-6750. 633 Court St 903 Diamond Park Mifflintown PA 17059. 1st Fl Meadville PA 16335 (717) 436-7706 Northumberland Wayne Reading PA 19601 (814) 333-7307 320 N 2nd St 925 Court St (610) 478-6490 Lackawanna Ste 1 Honesdale PA 18431. Cumberland 123 Wyoming Ave Sunbury PA 17801 (570) 253-5978. Blair 1601 Ritner Highway 2nd Floor (570) 988-4208. 279A Loop Road Ste 201 Scranton PA 18503 Westmoreland Hollidaysburg PA 16648 Carlisle PA 17013 (570) 963-6737 Perry 2 N Main St (814) 693-3287 (717) 240-6385 PO Box 37 Ste 109. Lancaster New Bloom ield PA 17068 Greensburg PA 15601. Bradford Dauphin PO Box 2139 (717) 582-2131 ext 4110 (724) 830-3150. 6 Court St 1251 South 28th Street Lancaster PA 17608. Ste 2 Harrisburg, PA 17111 (717) (717) 299-8293 Philadelphia Wyoming Towanda PA 18848 780-6360 520 N Columbus Blvd 1 Courthouse Sq (570) 265-1717 Lawrence Philadelphia PA Tunkhannock PA 18657.

8 Delaware 430 Court St 19123-4295 (570) 996-2226. Bucks Govt Center Bldg New Castle PA 16101 (215) 686-1590. 55 E Court St 201 W Front St (724) 656-2161 York Doylestown PA 18901-4318 Media PA 19063-2728 Pike 28 E Market St (215) 348-6163 (610) 891-4659 Lebanon 506 Broad St York PA 17401-1579. 400 S 8th St Milford PA 18337 (717) 771-9604. Butler Elk Municipal Bldg (570) 296-3427. PO Box 1208 300 Center St Rm 209. Butler PA 16003 PO Box 448 Lebanon PA 17042 Potter (724) 284-5308 Ridgway PA 15853-0448 (717) 228-4428 1 N Main St Ste 204 For a listing of available (814)776-5337 email addresses, go to Cambria Lehigh Coudersport PA 16915. 200 S Center St Erie 17 S 7th St (814) 274-8467 Ebensburg PA 15931 140 W 6th St Allentown PA 18101-2401. (814) 472-1464 Rm 112 (610) 782-3194 Schuylkill Erie PA 16501 420 N Centre St Pottsville Cameron (814) 451-6276 Luzerne PA 17901.

9 20 E Fifth St 20 N Pennsylvania Ave (570) 628-1467. Emporium PA 15834-1469 Fayette Ste 207. (814) 486-9321 22 E Main St Wilkes-Barre PA 18701 Snyder Public Service Bldg Uniontown (570) 825-1715 PO Box 217. Carbon PA 15401 Middleburg PA. 44 Susquehanna St (724) 430-1289 Lycoming 17842-0217 (570). PO Box 170 48 W Third St 837-4207. Jim Thorpe PA 18229-0170 Forest Williamsport PA 17701-9536. (570) 325-4801 526 Elm St (570) 327-2267 Somerset Box 3 300 N Center Ave Centre Tionesta PA 16353 McKean Ste 340. 420 Holmes St Willowbank (814) 755-3537 500 W Main St Somerset PA 15501 (814). Office Bldg Bellefonte PA Smethport PA 16749 445-1549. 16823-1486 (814) Franklin (814) 887-3203. 355-6703 272 N. Second Street Sullivan Chambersburg, PA 17201 245 Muncy St (717) 261-3886 PO Box 157. Laporte PA 18626. (570) 946-5201 ext 7. Page 3. Pennsylvania Voter Registration Application DSBE 02/2021.

10 Use black ink Last name Jr Sr II III IV. Print your name 1. First name Middle name or initial Eligibility Are you a citizen of the Yes No If you answer No to 2 Will you be 18 years or older either question, you cannot on or before election day? Yes No REGISTER to vote . New Registration Change of name Change of address Reason 3. Change of party Federal or State employee registering in county of last residence About you Birth date Sex M F Race (optional). Phone and email are optional 4. and used if information is Phone Email missing on this form. Address (not Box) Apt. number Your address If you do not have a street City/Town State PA Zip Code address or a permanent 5. residence, or are a student, Municipality County see the instructions. I do not have a street address or permanent residence (use map on back). The address where Same as above Address or Box 6.