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 www.dos.state.pa.us) 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. 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 identification. If this is the first election in which you are voting in your election district, 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. 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, www.dos.state.pa.us

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. 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. 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 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. 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. 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.

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ADDRESSES 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 form.

If 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 roads.

ADAMS COUNTY111-117 BALTIMORE ST 1ST FLGETTYSBURG PA 17325-2312(717) 337-9832

ALLEGHENY COUNTY542 FORBES AVE STE 604PITTSBURGH 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 166BEDFORD PA 15522-0166(814) 623-4807

BERKS COUNTY633 COURT STREADING PA 19601-3540(610) 478-6490

BLAIR COUNTY423 ALLEGHENY ST STE 043HOLLIDAYSBURG 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 1208BUTLER PA 16003-1208(724) 284-5308

CAMBRIA COUNTY200 S. CENTER STEBENSBURG PA 15931(814) 472-5440

CAMERON COUNTY20 E FIFTH STEMPORIUM PA 15834-1469(814) 486-2315

CARBON COUNTYBROADWAY & HAZARD SQ PO BOX 129JIM THORPE PA 18229-0129(570) 325-4801

CENTRE COUNTY420 HOLMES STBELLEFONTE PA 16823-1488(814) 355-6703

CHESTER COUNTY601 WESTTOWN RD PO BOX 2747WEST 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 108CLEARFIELD 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 380BLOOMSBURG PA 17815-0380(570) 389-5640

CRAWFORD COUNTY903 DIAMOND PARKMEADVILLE PA 16335-2678(814) 333-7306

CUMBERLAND COUNTY37 E HIGH ST STE 104CARLISLE PA 17013-3044(717) 240-6385

DAUPHIN COUNTYPO BOX 1295HARRISBURG 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 448RIDGWAY PA 15853(814) 776-5337

ERIE COUNTY140 W 6TH ST RM 105ERIE PA 16501-1096(814) 451-6275

FAYETTE COUNTY22 E MAIN ST PUBLIC SERVICE BLDGUNIONTOWN PA 15401(724) 430-1289

FOREST COUNTYPO BOX 126TIONESTA PA 16353-0126(814) 755-3537

FRANKLIN COUNTY157 LINCOLN WAY EASTCHAMBERSBURG PA 17201-2211(717) 261-3886

FULTON COUNTY116 W MARKET ST STE 203MCCONNELLSBURG PA 17233(717) 485-3691

GREENE COUNTY93 E HIGH ST RM 102WAYNESBURG 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 68MIFFLINTOWN PA 17059-0068(717) 436-7706

LACKAWANNA COUNTY135 JEFFERSON AVE SUITE 100SCRANTON PA 18503(570) 963-6737

LANCASTER COUNTYPO BOX 83480LANCASTER 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 1507SMETHPORT 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 105STROUDSBURG PA 18360-2170(570) 517-3165

MONTGOMERY COUNTYCOURTHOUSE PO BOX 311NORRISTOWN 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 37NEW 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 22ACOUDERSPORT PA 16915-1690(814) 274-8467

SCHUYLKILL COUNTY114 S CLAUDE A LORD BLVDPOTTSVILLE PA 17901-3602(570) 622-3040

SNYDER COUNTYPO BOX 217MIDDLEBURG PA 17842-0217(570) 837-4209

SOMERSET COUNTY300 N CENTER AVE STE 510SOMERSET PA 15501(814) 445-1549

SULLIVAN COUNTYPO BOX 157LAPORTE 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) 723-8230

UNION COUNTY103 S SECOND STLEWISBURG PA 17837-1996(570) 524-8681

VENANGO COUNTY1174 ELK ST PO BOX 831FRANKLIN PA 16323-0831(814) 432-9514

WARREN COUNTY204 FOURTH AVEWARREN PA 16365-2399(814) 728-3401

WASHINGTON COUNTY100 W BEAU ST RM 206WASHINGTON PA 15301(724) 228-6750

WAYNE COUNTY925 COURT STHONESDALE PA 18431-1996(570) 253-5978

WESTMORELAND COUNTY2 N MAIN ST STE 109GREENSBURG 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 to:www.dos.state.pa.usIf you are interested in becom-ing a poll worker, contact yourcounty voter registration office.

INSTRUCTIONS FOR FILLING OUT THIS FORM (PLEASE READ CAREFULLY)

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

Name on previous registration In which party do you wish to register?

DemocraticRepublicanLibertarianGreen

No affiliationOther (Please specify):

NAME CITY, BORO, OR TWP. WARD DISTRICT

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Place signature with full name (or mark) below.(Please see Penalty for Falsifying Declaration.)

Date of Birth Race (Optional)

Print Your Name Below

Address

Year of previous registrationAddress of previous registration

Date

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County of previous registrationa

PENNSYLVANIA VOTER REGISTRATION APPLICATION

DO NOT WRITE IN SHADED AREAS

Apt #

COUNTY VOTER I.D.#

Name of person who assisted in the completion of this application

AND I HEREBY AFFIRM THAT the information I have provided in this registrationdeclaration is true. I understand that this registration declaration will be acceptedfor all purposes as the equivalent of an affidavit; and if the registration contains amaterially false statement, I will be subject to penalties for perjury.

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WARNING: If a person signs an official registration application knowing astatement declared in the application to be false, makes a false registration, orfurnishes false information, the person commits perjury. Perjury is punishable,upon conviction, by a term of imprisonment not exceeding seven years, or a finenot exceeding $15,000, or both, at the discretion of the court. Submitting anapplication containing false information may also subject a person to otherpenalties, including loss of the right of suffrage, under state or federal law.

PENALTY FOR FALSIFYING REGISTRATION DECLARATION

Mailing Address: Fill in mailing address, if different from Box 4a.Date of Birth: Fill in month, day and year of your birth.Race: Fill in your race. (Optional)

Prior Registration: If you were registered before, fill in name of previousregistration in Box 8a and address, county and year of previous registra-tion in Box 8b.Political Party: Check block for political party or no affiliation. You mustregister with a party if you want to take part in that party's primary.

If you were assigned a Voter Identification Number, which appears onyour Voter Identification Card, place that Identification Number here. Ifyou are applying to register to vote for the first time leave this box blank.

Registration Declaration: 11a You must be a citizen of the United Statesto register to vote in the Commonwealth of Pennsylvania.11b Please readthe registration declaration carefully. Please sign and print your name anddate the application.

Zip Code 4b

Zip CodeStateCityMailing address (if different than address of residence)County where you liveMunicipality where you live 54c

4a

State

Middle Name/InitialFirst NameLast Name32 New Registration Change of Name Change of Address Change of Party

Are you a citizen of the United States of America?Will you be 18 years of age on or before election day?

Yes No Yes No }

Citizenship and Age: If the answer to either question is "No," do notcomplete this form because you are not eligible to register to vote.Application Type: Please check the appropriate box. If you are a Federalor State employee and wish to retain your voting residence in the countywhere you last resided, please check the appropriate box. Name, Driver's License and Social Security Number: Print last name,first name and middle name or initial. Circle Jr., Sr., II, III, IV if applica-ble. You must supply a Driver's License Number, if you have one. If youdo not have a Driver's License Number, you must supply the last four dig-its of your Social Security Number. If you do not have a Social SecurityNumber, please write None in the boxes. 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 ofthe house, include the location or number of the room, apartment or floorwhich is occupied.) In Box 4b include your telephone number. (Optional) In Box 4c fill in the name of the municipality (city, borough or town-ship) and county where you live. Use the map in the box below if you can-not otherwise identify your address.

If you checked "No" in response to either of thesequestions, do not complete this form.

Box 5.Box 6.Box 7.Box 8.

Name of Assistant: If the applicant is unable to sign the application, theperson who assisted the applicant must provide his or her name, addressand telephone number.

Box 12.

MrMrsMiss

DL #

OR SS# (last 4 digits)

( )

Voter IdentificationNumberI HEREBY DECLARE THAT:

PARTY AFFILIATIONYEARREGISTRARDATE OF REGISTRATION

PA

Jr Sr II III IV

Box 1.

Box 2.

Box 4.

Box 3.

Place either Driver's License # or Social Security # here

(1)On the day of the next election I will have been a United States citizen forat least one month, I will be at least 18 years of age, and I will haveresided in Pennsylvania and in my election district for at least 30 days;

(2)I am legally qualified to vote.

Box 9.

Box 10.

Box 11.

my voting residence in the county where I last resided.I am a Federal or State employee and wish to retain