Pennsylvania Voter Registration Application Form General ...

1 Pennsylvania Voter Registration Application form 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 to vote. 3. In order to vote at the next election, this Application must be received by your county Voter Registration office 30 days before the election, or postmarked no later than the thirtieth day before the election. Military electors may apply at any time. 4. Print out, fill in completely, sign and date the form . Place completed Application in an envelope addressed to your local county Voter Registration office (addresses are available on the web at ) and affix the proper postage. 5. You are not registered to vote until your Application has been processed and accepted by the county Voter Registration office.

2 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. IDENTIFICATION WHEN YOU VOTE Pennsylvania law requires that registered voters who appear to vote for the first time in an election district after December 9, 2003 must present a form of id en tification. If th is is the first election in which you are voting in your election distr ict, and you intend to vote by absentee ballot in an election after January 1, 2004, you may include a form of identification with this Voter Registration Application form rather than include it with your Application for an absentee ballot.

3 A list of the acceptable forms of identification may be obtained from your county Voter Registration office or from the Pennsylvania Department of State at its website, INSTRUCTIONS FOR FILLING OUT THIS form (PLEASE READ CAREFULLY) Box 1. Citizenship and Age: If the answer to either question is No, do not complete this form because you are not eligible to register to vote. Box 2. Application Type: Please check the appropriate box. If you are a Federal or State employee and wish to retain your voting residence in the county where you last resided, please check the appropriate box. Box 3. Name, Driver s License and Social Security Number: Print your last name, first name and middle name or initial. Circle Jr., Sr., II, III, IV if applicable. You must supply a Driver s License Number if you have one. If you do not have a Driver s License Number, you must supply the last four digits of your Social Security Number.

4 If you do not have a Social Security Number, please write None in the boxes. Box 4: 4a. Address of Residence: Fill in your complete address of residence. 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 or number of the room, apartment or floor, which is occupied.) In Box 4b include your telephone number (Optional). 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. If your address of residence listed in Box 4a has no street number or street name (for example, Schoolhouse Road or RR2 Box 3) use the box above to draw a map of where you live.

5 Include landmarks and roads. Box 5. Mailing Address: Fill in your mailing address, if different from Box 4a. Box 6. Date of Birth: Fill in the month, day and year of your birth. Box 7. Race: Fill in your race (Optional). Box 8. Prior Registration : If you were registered before, fill in the name used on previous Registration in Box 8a and address, county and year of previous Registration in Box 8b. Box 9. Political Party: Check block for political party or no affiliation. You must register with a party if you want to take part in that party s primary. Box 10. If you were assigned a Voter Identification Number, which appears on your Voter Identification Card, place that Identification Number here. If you are applying to register to vote for the first time, leave this box blank. Box 11. Registration Declaration: You must be a citizen of the United States to register to vote in the Commonwealth of Pennsylvania .

6 Please read the Registration declaration carefully. Please sign and print your name and date the Application . 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. Box 12. Name of Assistant: If the applicant is unable to sign the Application , the person who assisted the applicant must provide his or her name, address and telephone number.

7 Filename: i:\f3jobs\win_f3\1182828\ , Date: 1-24-103 15:08:56 Sheet: 1, Copy: Front, Scale: 100%, Type: ManufacturingFMOISTENMOISTENA dhesive7/16 in. Remoist Full HorizontalAdhesive3/8 in. RemoistPartialoistEndadhesive hereesivePerforationRule Weight= ptFill screen=100% HorizontalFold perffull Weight= ptReverseFullHorizontalMOISTEN 3 SIDES FOLD SEAL AND MAILMOISTENMOISTENFOLDFOLDADDRESSES OF COUNTY Voter Registration OFFICESTo mail this Application , write the address of the County Voter Registration Office in the proper area on the reverse side of this your address of residence listed in Box 4a has no street number or streetname (for example, Schoolhouse Road or RR2 Box 3) use the box aboveto draw a map of where you live. Include landmarks and COUNTY111-117 BALTIMORE ST 1ST FLGETTYSBURG PA 17325-2312(717) 337-9832 ALLEGHENY COUNTY542 FORBES AVE STE 604 PITTSBURGH PA 15219-2953(412) 350-4500 ARMSTRONG COUNTYADMIN/BLDG 500 E MARKET STKITTANNING PA 16201(724) 548-3222 BEAVER COUNTY810 THIRD STBEAVER PA 15009-2145(724) 728-3934 EXT 11298 BEDFORD COUNTY211 S JULIANA ST PO BOX 166 BEDFORD PA 15522-0166(814) 623-4807 BERKS COUNTY633 COURT STREADING PA 19601-3540(610) 478-6490 BLAIR COUNTY423 ALLEGHENY ST STE 043 HOLLIDAYSBURG PA 16648-2022(814) 693-3150 BRADFORD COUNTY301 MAIN STTOWANDA PA 18848-1878(570) 265-1717 BUCKS COUNTY55 E COURT STDOYLESTOWN PA 18901-4318(215) 348-6163 BUTLER COUNTYPO BOX 1208 BUTLER PA 16003-1208(724) 284-5308 CAMBRIA COUNTY200 S.

8 CENTER STEBENSBURG PA 15931(814) 472-5440 CAMERON COUNTY20 E FIFTH STEMPORIUM PA 15834-1469(814) 486-2315 CARBON COUNTYBROADWAY & HAZARD SQ PO BOX 129 JIM THORPE PA 18229-0129(570) 325-4801 CENTRE COUNTY420 HOLMES STBELLEFONTE PA 16823-1488(814) 355-6703 CHESTER COUNTY601 WESTTOWN RD PO BOX 2747 WEST CHESTER PA 19380-0990(610) 344-6410 CLARION COUNTY421 MAIN STCLARION PA 16214-1093(814) 226-4000 EXT 2205 CLEARFIELD COUNTY230 E MARKET ST STE 108 CLEARFIELD PA 16830(814) 765-2641 EXT 5996 CLINTON COUNTY232 E MAIN ST GARDEN BLDG 3RD FLLOCK HAVEN PA 17745-1385(570) 893-4019 COLUMBIA COUNTY35 W MAIN ST PO BOX 380 BLOOMSBURG PA 17815-0380(570) 389-5640 CRAWFORD COUNTY903 DIAMOND PARKMEADVILLE PA 16335-2678(814) 333-7306 CUMBERLAND COUNTY37 E HIGH ST STE 104 CARLISLE PA 17013-3044(717) 240-6385 DAUPHIN COUNTYPO BOX 1295 HARRISBURG PA 17108-1295(717) 255-2793 DELAWARE COUNTYGOV'T CENTER BLDG 201 W FRONT STMEDIA PA 19063-2728(610) 891-4659 ELK COUNTY300 CENTER ST PO BOX 448 RIDGWAY PA 15853(814) 776-5337 ERIE COUNTY140 W 6TH ST RM 105 ERIE PA 16501-1096(814) 451-6275 FAYETTE COUNTY22 E MAIN ST PUBLIC SERVICE BLDGUNIONTOWN PA 15401(724) 430-1289 FOREST COUNTYPO BOX 126 TIONESTA PA 16353-0126(814) 755-3537 FRANKLIN COUNTY157 LINCOLN WAY EASTCHAMBERSBURG PA 17201-2211(717) 261-3886 FULTON COUNTY116 W MARKET ST STE 203 MCCONNELLSBURG PA 17233(717) 485-3691 GREENE COUNTY93 E HIGH ST RM 102 WAYNESBURG PA 15370(724) 852-5230 HUNTINGDON COUNTY223 PENN ST COURTHOUSEHUNTINGDON PA 16652-1486(814) 643-3091 INDIANA COUNTY825 PHILADELPHIA STINDIANA PA 15701-3934(724) 465-3852 JEFFERSON COUNTY155 MAIN ST JEFFERSON PLACEBROOKVILLE PA 15825-1269(814) 849-1605 JUNIATA COUNTYBRIDGE ST PO BOX 68 MIFFLINTOWN PA 17059-0068(717)

9 436-7706 LACKAWANNA COUNTY135 JEFFERSON AVE SUITE 100 SCRANTON PA 18503(570) 963-6737 LANCASTER COUNTYPO BOX 83480 LANCASTER PA 17608-3480(717) 299-8293 LAWRENCE COUNTY430 COURT STNEW CASTLE PA 16101-3593(724) 656-2161 LEBANON COUNTY400 S EIGHTH STLEBANON PA 17042-6794(717) 274-2801 EXT 2243 LEHIGH COUNTY17 S 7TH STALLENTOWN PA 18101-2400(610) 782-3194 LUZERNE COUNTY200 N RIVER STWILKES-BARRE PA 18711(570) 825-1715 LYCOMING COUNTY48 W THIRD STWILLIAMSPORT PA 17701-0536(570) 327-2267 MCKEAN COUNTYPO BOX 1507 SMETHPORT PA 16749-0507(814) 887-3203 MERCER COUNTY#5 COURTHOUSEMERCER PA 16137-1227(724) 662-3800 EXT 2240 MIFFLIN COUNTY20 N WAYNE STLEWISTOWN PA 17044(717) 248-6571 MONROE COUNTYONE QUAKER PLAZA RM 105 STROUDSBURG PA 18360-2170(570) 517-3165 MONTGOMERY COUNTYCOURTHOUSE PO BOX 311 NORRISTOWN PA 19404-0311(610) 278-3280 MONTOUR COUNTY29 MILL STDANVILLE PA 17821(570) 271-3000 NORTHAMPTON COUNTYWOLF BLDG 45 N SECOND STEASTON PA 18042-3695(610) 559-3055 NORTHUMBERLAND COUNTY609 MARKET STSUNBURY PA 17801-2360(570) 988-4208 PERRY COUNTYPO BOX 37 NEW BLOOMFIELD PA 17068-0037(717) 582-2131 EXT 4110 PHILADELPHIA COUNTY520 N DELAWARE AVE 5TH FLPHILADELPHIA PA 19123-4295(215) 686-1505 PIKE COUNTY506 BROAD STMILFORD PA 18337-1535(570) 296-3426 POTTER COUNTY1 E SECOND ST RM 22 ACOUDERSPORT PA 16915-1690(814) 274-8467 SCHUYLKILL COUNTY114 S CLAUDE A LORD BLVDPOTTSVILLE PA 17901-3602(570) 622-3040 SNYDER COUNTYPO BOX 217 MIDDLEBURG PA 17842-0217(570) 837-4209 SOMERSET COUNTY300 N CENTER AVE STE 510 SOMERSET PA 15501(814) 445-1549 SULLIVAN COUNTYPO BOX 157 LAPORTE PA 18626-0157(570) 946-5201 SUSQUEHANNA COUNTYPO BOX 218 MAPLE STMONTROSE PA 18801-0218(570) 278-4600 EXT 220 TIOGA COUNTYPO BOX 589 118 MAIN STWELLSBORO PA 16901-0589(570)

10 723-8230 UNION COUNTY103 S SECOND STLEWISBURG PA 17837-1996(570) 524-8681 VENANGO COUNTY1174 ELK ST PO BOX 831 FRANKLIN PA 16323-0831(814) 432-9514 WARREN COUNTY204 FOURTH AVEWARREN PA 16365-2399(814) 728-3401 WASHINGTON COUNTY100 W BEAU ST RM 206 WASHINGTON PA 15301(724) 228-6750 WAYNE COUNTY925 COURT STHONESDALE PA 18431-1996(570) 253-5978 WESTMORELAND COUNTY2 N MAIN ST STE 109 GREENSBURG PA 15601(724) 830-3150 WYOMING COUNTY1 COURTHOUSE SQTUNKHANNOCK PA 18657-1216(570) 996-2226 YORK COUNTY1 WEST MARKETWAYYORK PA 17401-1256(717) 771-9604 For a listing of availablecounty e-mail addresses, go you are interested in becom-ing a poll worker, contact yourcounty Voter Registration FOR FILLING OUT THIS form (PLEASE READ CAREFULLY)Rule, Weight= ptScreen=10%, 150 line16 78 912 Telephone Number (Optional)Address of residence, include street and city (Use map above if no street number or name) (If only box, see above)Name on previous registrationIn which party do you wish to register?