New York State Voter Registration Form Register to vote Send or deliver this form Verifying your identity With this form, you register to vote in elections in New York State. You can also use this form to: FiU out the form below and send it to your county's address on the back of this form, or take this form to the office of your County Board of Elections. We'll try to check your identity before Election Day, through the DMV number (driver's license number or non-driver 10 numberl, or the last Mail or deliver this form atleast 25 days before the election you want to vote in. Your county will notify you that you are registered to vote. To register you must Questions? • be a US citizen: Call your County Board of Elections If you do not heve a DMV or social security number, you may use a valid photo 10, a current utility bill, bank statement. paycheck, government check or some other government document that shows your name and address. You may include a copy of one of those types of 10 with this form be sure to tape the sides of the form closed. • not claim the right to vote elsewhere. www.elections.state.ny.us If we are unable to verify your identity before Election Day, you wlll.be asked fO.r ID when you vote for the first time. Infarmaci6n en espanal: si Ie interesa abtener este farmularia en espanal, lIameaJ1-800-367-8683 ~'iil; 1-800-367-8683 'PXSi.f"';:f!if&\1f!llMm~~'Px'i(~~jItr, ~~oj; ~~oj 0J~% 'tJ."5~Al';1 o Find answers or tools on ou:r website 1-800-367-8683 2-5'. ~[§} "5~1JAI.2-. It is a crime to procure a false registration or to furnish false information to the Board of Elections. Are you a citizen of the U.S.? ;\J'[ Ilnt/iSllli which you'll fill in below. listed on the back of this form or 1-800-FORNOTE (TOO/TTY Oia1711) • be 18 years old by the end ofthis year; • not be in prison or on parole for a felony conviction; o four dIgits of your social.security number, • change the name or address on your voter registratIon • become a member of a political party • change your party membership Qualifications o Yes 0 Please print In blue or black ink. No If you answer No, you cannot register to vote. Will you be 18 years of age or older on or before election o Yes o No If you answer No, you cannot register to vote unless you will be 18 by the end of the year. Last name Suffix First name Middle Initial Birth date Sex Your name More information 0 M OF Address (not P.O. Box) The address where you live Apt. Number Zip code City/TownlVillage New York State County The address where you receive mail Skip if same as above Address or P.O. Box P.O. Box Zip code City/TownlVillage Voting history Have you voted before? Voting information that has changed Your name was Skip if this has not changed or you have not voted before Identification You must make 1 selection For questions, please refer to Venfying your identity above. Political party You must make 1 selection To vote in a primary election, you must be enrolled In one of these listed partiesexcept the Independence Party, which permits non-enrolled voters to participate in certain primary elections. Optional questions o Yes o No What year? Your address was Your previous state or New York State County was ... .....••... . . _ _.._.._.... ..•...... -_.. _.........• _._ _ . o New York State DMV number o Last four digits of your Social Security number x x x - x x o I do not have a l\Jew York State driver's license or a Social Security number. o Democratic party Affidavit: I swear or affirm that o Republican party o Independence party o Conservative party vote o Working Families party o Other _ o I do not wish to enroll in a party • I am a citizen of the United States. • I will have lived in the county, city or village for at least 30 days before the elecliOn. • I meet all requirements to register to in New York State. • This IS my signature or mark In the box below. • The above information is true, I understand that if it is not true, I can be convicted and fined up to $5,000 and/or Jailed for up to four years. o I need to apply for an Absentee ballot (optional). o I would like to be an Election Day worker (optional). Sign Date Address and sta:mp thiis section Your address Place First-class stamp here Your County Board of Elections address (select from below) Before mailing Remove tape, fold and seal New York City Executive Offices 32 Broadway, 7th FI. I NeWYOrk';j 10004 Chenango 5CourtSt Norwich, NY 13815 Franklin 355 West Main St Ste 161 Malone, NY 12953 (6071337-1760 Clinton (~1_~~87-5300 Cnty Government Ctr 137 Margaret St Albany Ste 104 32 North Russell Road Plattsburgh, NY 12901 Albany, NY 12206 (518) 487·5060 Allegany 6 Schuyler St Belmont, NY 14813 (5851268-9294 Broome Government Plaza 44 HawleySt PO Box 1766 Binghamton, NY 13902 (607) 778·2172 (315) 253·1285 (716)753-4580 Chemung 37B South Main St. PO Box 588 Elmira, NY 14902 (607) 737·5475 Oneida Union Station 321 MainSt 3rd FI UlIca, NY 13501 13151376-5329 (518) 481·1663 Livingston Fulton County Govt Ctr 2714 St. Hwy 29 6CourtSt Ste 1 Room 104 Johnstown, NY 12095 Geneseo, NY 14454 (315) 798-5765 (5181565-4740 (518) 736-5526 (585) 243·7090 Columbia 401 State St. Hudson, NY 12534 Genssee County BUilding #1 15 Main St. PO Box284 Batavia, NY 14021 Madison County Office Bldg N CourtSt. PO Box666 Wampsville, NY 13163 (585) 344-2550 (315) 366-2231 (518) 828·3115 Cortland 112 River St Room 103 Cortland, NY 13045 (607) 753·5032 Delaware 3 Gallant Ave. Deihl, NY 13753 Cattaraugus (607) 746-2315 302 CourtSt. Little Valley, NY 14755 Dutchess (716) 938·2400 47 Cannon St. PoughkeepSie, NY Cayuga 12601 10 CourtSt (845) 486-2473 Auburn, NY 13021 Chautauqua 7 North Erie St Mayville, NY 14757 Lewis 7660 N State St Lowville, NY 13367 Erie 134 WEagle St Buffalo, NY 14202 (716) 858-8891 Essex 7551 Court St PO Box217 Elizabethtown, NY 12932 Greene 411 MalnSt. Ste.437 CatsKill, NY 12414 Monroe 39 Main St W. Rochester, NY 14614 (585) 753-1550 (518) 719-3550 Hamilton Rte.8 PO Box 175 Lake Pleasant, NY 12108 Onondaga CivicCtr 421 Montgomery St., 15th FI Syracuse, NY 13202 (315) 435-3312 Ontario (518) 761-6456 One D1Pronio Dr Rockland Steuben 11 New Hempstead Rd 3 E Pulteney Sq New City, NY 10956 Batn, NY 14810 48CourtSt Canton, NY 13617 Orange 25 Court Lane PO Box 30 Goshen, NY 10924 (315) 379-2202 Suffolk PO Box700 Yaphank Ave Yaphank, NY 11980 (518) 853·8180 (585) 589·3274 Nassau 240 Old Country Rd. 5th FI Mineola, NY 11501 Oswego 185 E Seneca St Box9 Oswego, NY 13126 (516) 571·2411 (315) 349·8350 (7161438·4040 (315) 539-1760 (585) 396·4005 (315) 867-1102 (315) 785·3027 Waterloo, NY 13165 (518) 270-2990 Seneca (607) 664·2260 Orleans 14012 State Rte. 31 Albion, NY 14411 (845) 334-5470 Warren Cnty Municipal Ctr 1340 St. Rte. 9 Lake George, NY 12845 (607) 535·8195 St. lawrence (845) 291·2444 Ulster 284WaiiSt. Kingston, NY 12401 Renssalaer Ned Pattison Government Ctr 1600 Seventh Ave Troy. NY 12180 (845) 638·5172 Montgomery Old Courthouse 9 ParkSt PO Box 1500 Fonda. NY 12068 Niagara Jefferson 111 MalnSt. 175 Arsenal St Ste.l00 Watertown, NY 13601 Lock port, NY 14094 (845) 278-6970 Schuyler County Office Bldg. 1059thSt., Unit 13 Watkins Glen, NY 14891 74 Ontario St. Canandaigua, NY 14424 (518) 548-4684 Herkimer 109 Mary St. Ste 1306 Herkimer, NY 13350 Putnam 1 Geneva Rd Brewster, NY 10509 (631) 852-4500 Saratoga (5181885-2249 Schenectady 388 Broadway, Ste E Schenectady, NY 12305 (518) 377·2469 Schoharie County Office Bldg. 284Main St PO Box99 Schoharie, NY 12157 Otsego Ste.2 140 County Hwy. 33W (518) 295·8388 Cooperstown, NY 13326 (518) 746-2180 Wayne 157 Montezuma St. Ext PO Box636 Lyons, NY 14489 (315) 946·7400 Sullivan 50W HighSt Ballston Spa, NY 12020 Washington 383 Broadway Fort Edward, NY 12828 Westchester Gov't.Ctr. 100 NorthSt PO Box5017 Monticello, NY 12701 25 Quarropas St. White Plains, NY 10601 (845) 807-0400 1914) 995·5700 Tioga County Office Bldg. 56 MainSt. Owego, NY 13827 Wyoming 4 Perry Ave. Warsaw, NY 14569 (585) 786-8931 (607) 687-8261 Tompkins Court House Annex 128 E. Buffalo St. Ithaca, NY 14850 Yates Ste.1124 417 Liberty St. Penn Yan, NY 14527 (315) 536·5135 (607) 274·5522 (607) 547-4247 (5181873·3474 I : (Optional) Register t~ don.ate y~ur,org~ns and tiss:u~s may If you would like to be an organ and tfssue donor, yOip emoll 1.0 the NYS Department of Health (DOH) Donate Life Tl1Registry oohne at www.nyhealth.gov or proVide your name aod a~dress below. You ~J11 receIVe a conflrifo\atlOn.letter from DOH, which will also provide you an opportunity to hmltyour donation. DQJATE LiFE I By signing below, you certify that you are: Last name ------- - - - - ---~-- First name • 18 years of age or older; Middle Initial • consenting to donate all of your organs and tissues for transplantation, research, or both; Suffix • authorizing the Board of Elections to provide your name and identifying information to DOH for enrollment in the Registry; Address Apt. Number Zip code • and authorizing DOH to allow access to this in formation to federally regulated organ procure ment organizations and NYS-licensed tissue and eye banks and hospitals upon your death. City Sex Eye color Height 0 I\t1..................OF -_ . In. Sign Date