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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 ID 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. NAME/ADDRESS CHANGE. Complete these sections to change the name or address of your current voter registration. 9. MAP/DIAGRAM: 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 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 Place copy of ID in pocket Trim copy of ID to size Signature of person helping illiterate or disabled voter Date Signature X I SWEAR OR AFFIRM: Are you a citizen of the United States of America? Check One: Will you be 18 years of age on or before election day? Check One: If you checked “No” in response to either of these questions, do not complete this form. I SWEAR OR AFFIRM THAT: I reside at the address listed above. I am eligible 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. Yes No Yes No VALID GA. DRIVER’S LICENSE OR GA. I.D. NO. Check if you do not have a GA Driver’s License, GA. I.D. No. or Social Security No. If no GA Driver’s License or GA. I.D. No., must provide last 4 digits of your Social Security Number (Your answer is required under federal law) 5 6 FULL SOCIAL SECURITY NUMBER (OPTIONAL) 4 TELEPHONE NUMBER ( ) DATE OF BIRTH: MM/DD/YYYY GENDER RACE/ ETHNICITY: Last 4 Digits (Required) 4 TELEPHONE NUMBER ( ) GENDER Male Female LAST NAME FIRST NAME MIDDLE OR MAIDEN NAME 1 2 RESIDENCE ADDRESS: House No. and street name APT. NO. CITY COUNTY SUFFIX Jr. Sr. II III IV V STATE GA. ZIP CODE 3 MAILING ADDRESS (If different from residence address): Post-office box or route CITY STATE ZIP CODE OFFICE USE ONLY MUNICIPAL PRECINCT DISTRICT COMBO DDS APLICATION NO. REGISTRATION NO. COUNTY PRECINCT CHANGE OF ADDRESS CHANGE OF NAME DATE OF BIRTH: MM/DD/YYYY RACE/ ETHNICITY: White Hispanic/Latino Black American Indian Asian/Pacific Islander WARNING: Any person who registers to vote knowing that such person does not possess the qualifications required by law, who registers under any name other than such person’s own name, or who knowingly gives false information in registering shall be guilty of a felony. O.C.G.A. § 21-2-561 May we contac Election Day poll officer If you would like mation by email, please provide your e-mail address: t you about working as an ? to receive additional infor 8 7 Military Active Duty? Yes No CHANGE OF NAME: If you are changing your name, list the name under which you were previously registered: CHANGE OF ADDRESS: If you are changing your address or if you were previously registered to vote, list your previous address: CITY COUNTY Last Name Suffix First Middle or Maiden Name Yes No STATE REQUIREMENT: If you are submitting this form by mail and you are registering for the first time in Georgia, you are required to submit proof of residence either with this form OR when you vote for the first time. Proof of residence includes one of the following: a COPY of a current and valid photo ID; or a COPY of a current utility bill, bank statement, government check, paycheck, or other government document that shows your name and address. You are exempt from this requirement if you are entitled to vote by absentee ballot under the Uniform and Overseas Citizens Absentee Voting Act, or if you provide your Georgia driver's license/ID number (or the last four digits of your social security number if you do not have a driver's license/ID) on this form and your identifying information is verified with a state database. 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. 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.ga.gov/elections. ---PAGE BREAK--- www.sos.ga.gov/elections.