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- - - - - - - STATE OF GEORGIA APPLICATION FOR VOTER REGISTRATION Fill out the bottom half of this application by following these directions. Print clearly and use blue or black ink. 1. LEGAL NAME. Your full legal name including any suffix such as Sr., Jr., III, is required on this form. 2. ADDRESS. Provide residential address. This information is required. 3. MAILING ADDRESS. If mailing address is different from residential address, complete the mailing address section. 4. PERSONAL INFORMATION. A telephone number is helpful to registration officials if they have a question about your application. Gender and race are requested and are needed to comply with the Voting Rights Act of 1965, but are not mandated by law. 5. VOTER IDENTIFICATION NUMBER. Federal law requires you to provide your full GA Drivers License number or GA State issued LD number. If you do not have a GA Drivers License or GA ID you must provide the last 4 digits of your Social Security number. Providing your full Social Security number is optional. Your Social Security number will be kept confidential and may be used for comparison with other state agency databases for voter registration identification purposes. If you do not possess a GA Drivers License or Social Security number please check the appropriate box and a unique identifier will be provided for you. 6. OATH. Federal law requires that you answer the citizenship and age questions. Read the oath and sign your name. If you cannot complete this application unassisted because of physical disability or illiteracy, you must either sign or make your mark on the signature line, and the person assisting you MUST sign the signature space for person assisting voter. 7. POLL OFFICER QUESTION. Your willingness to be a poll worker will have no bearing on your application for registration. 8. NAMEIADDRESS CHANGE. Complete these sections to change the name or address of your current voter registration. 9. MAPIDIAGRAM. If you live in an area without house numbers and street names, please include a drawing of your location to assist us in locating your appropriate voting precinct. 10. DELIVERY INSTRUCTIONS. Verify that you have completed and signed the application. Enclose a copy of your ID if you are submitting this form by mail and registering for the first time in Georgia. Fold the application in half, remove the tape at the top, and press the edges together. The application is ready for you to mail (postage is prepaid) or deliver to your county voter registration office. 11. You are NOT officially registered to vote until this application is approved. You should receive a voter precinct card in the mail. If you do not receive this acknowledgement within two to four weeks after mailing this form, please contact your county voter registration office. You can find your poll location and other election information on the Secretary of State's website at www.sos.state.ga.us/elections. C , REQUIREMENT: If you are submitting this form by mail and you are registering for the first time in Georgia, enclose a copy of one of the @ following with your application: A copy of a current and valid photo ID, a copy of a current utility bill, bank statement, government check, paycheck, or other government document that shows your name and address. Those who are entitled to vote by absentee ballot under the Uniform and Overseas Citizens Absentee Voting Act arc exempt from this requirement. Placc copy of Trim copy of IDinpocket . ~ a a ID to size . . . - - . . . - . . ~ . . - . . . . CHANGE OF ADDRESS CHANGE OF NAME 0'I'HI:K 1 2 3 4 ( 6 7 LAST NAME FIRST NAME ZIP CODE ZIP CODE MIDDLE OR MAIDEN NAME RESIDENCE ADDRESS: House No. and street name SUFFIX ~ r . sr. 11 111 IV v APT NO. TELEPHONE NUMBER ) CI'I'Y STATE MAILING ADDRESS (If different from residence address): Post-officc box or routc DATE OFBIRTH: MMIDDIYYYY I I CITY COUNTY GENDER Male VALID GA. DRIVER'S LICENSE OR GA. 1.D. NO. UnIIIm S'I'A'I'E GA. RACE I ETHNICITY: Black White Hispaniclhtino Asian~Pacific Islander American Indian Othcr ll no GA. Driver's License or GA. 1.D. No. must provide last 4 digits of your Social Security Number FULLSOCIAI. SECURITY NUMBEK (OPTIONAL) h r t 4 diglls (Required) UcIIuIn cheek ifyou do not a GA Driver's License. GA. 1.D. No. or Social Sccurity No. (Your answer is required under federal law) I SWEAR OR AFFIRM: Are you a citizen of the United States of America? Check One Yes [7 No person does not possess the qualifications required by law, who Will you be IS years of age on or bcfore election day? Check One Yes No registers under any name other than such person's own name, or If you checked "No" in response to either of these questions, do not complete this form. who knowingly gives false information in registering shall he 1 SWEAR OR AFFIRM THAT: I reside ar the address listed above. 1 am elixible to vote in Georgia. I am not serving a sentence for having been convicted of a felony involving moral turpitude. I have not been judicially declared to be mentally incompetent. X Date Signature Signaturc of pct-son helping illiterate or disabled voter Military Active Duty? Yes NO May we contact you about working as an Election Day poll ofticer: Yes No If you would like to receive additional information by email. please provide your e-mail address: 8 CHANGE OFNAME: If you are changing your name, list the name under which you were previously registexd: bst Nilme Suffix First Middlc or Maidell Name CHANGE OF ADDRESS: If you are chanpine your d d r c s or iCyou were previously registered to vote. list your previous address: CITY COUNTY STATE ---PAGE BREAK--- DO NOT FOLD OVER, STAPLE OR TAPE NECESSARY IF MAILED IN THE h WUSllMESS REPLY MAIL FIRST-CLASS MAIL PERMIT NO. 19242 ATLANTA GEORGIA POSTAGE WILL BE PAID BY ADDRESSEE HON. KAREN HANDEL SECRETARY OF STATE STATE OF GEORGIA PO BOX 105325 ATLANTA GA 30348-9562 - STATE OF GEORGIA APPLICATION FOR VOTER REGISTRATION If you meet the following qualifications, complete this form and personally mail to the Secretary of State or personally deliver to your county voter registration office. Prepaid postage is provided for your convenience. QUALIFICATIONS: To register to vote you must: - Be a citizen of the United States - Be a legal resident of the county - Be at least 17Y2 years of age to register and 18 to vote - Not be serving a sentence for conviction of a felony involving moral turpitude - Have not been found mentally incompetent by a judge See other side for complete instructions. Once you complete and personally mail or deliver your application, you should receive an acknowledgement from the local voter registration office. Generally this process takes two to four weeks. To follow up on your voter registration application or to obtain more information on voter registration and elections, just call your local voter registration office. GENERAL INFORMATION: For more information on election dates, registration deadlines, and local county voter registration telephone numbers, see the Secretary of State's website at WWW.SOS.STATE.GA.USIELECTI0NS. HON. KAREN HANDEL SECRETARY OF STATE 1104 West Tower 2 Martin Luther King, Jr. Dr. SE Atlanta, Georgia 30334-1505 Telephone: (404) 656-2871