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1104
<br />North Carolina Voter Registration Application/Update Form
<br />A, Information
<br />You can use this form to:
<br />Register to vote in your count/ at residence in North Carolina, or chance your votat information
<br />If you are not sure if you are fagaaered, call your county board or areal Dmca
<br />Qualifications:
<br />■ You may register to vote only in the county where you reside.
<br />■ You must be a US citizen try birth or naturalization, end stnrm this in the Answer Firsr box ahowo below
<br />• You must be to years of age by rho next general election, and affirm this in the Answer First box shown below
<br />• It you have been convicted or a telony, youi rights of citizenship must be restored (After the completion of any
<br />sentence, including probation or parole. North Carolina restores your citizenship )
<br />Requirements:
<br />• Compiata the •ceceonc below by printing legibly.
<br />• It you ansv'rered YES to both questions in me Answer First box the hiormaton required m process this application
<br />includes: name residence address date of birch, and signature.
<br />•You may real or hand deliver thia tore to the board of elienone in The county where you live
<br />rfyou choose to we this roan to register fo veto, the location when; you have received this Pone will remain confidential and will box used
<br />any for voter registration purposes !f you dachns to register to vote the tact That you so declined will remain conrld6n0'al and will be
<br />used only forVokYrogistrafion purposes
<br />Pleaca detach Dafore malting
<br />_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _., ._ ..._ _ �. _ _ _ _ _ _ _ _ _ _ — — _ _ _ _ _ _ — _
<br />B. Cancel Your Previous Registration in Another County or State pg
<br />Ifyou were previously registered la Vote in another county or State, you uvuvevaetnwaacvan n�mWCOrryav na.. na masonalt]ce aru
<br />must fill out the information below to cancel your prior registration envier, .'euewvlive
<br />Name:
<br />Previous Name:
<br />Previous Address:
<br />Previous Cirystatc/ZIP Code:,
<br />County of Previous Residence:
<br />Dale of Binh: _/_I Place of Birth:__.
<br />Signature:
<br />---] F-
<br />u Wrun In the rem;: a Iha ecciwowts (or
<br />week) near", 6a whets you uvo. e.vn.,om
<br />• Draw in xtwhvnwhare YOUlrve. .1
<br />• Uae a 4, a to snow anY SnNOOk, cnurthas, REm pv »'
<br />,see, ar finer inlmeM nearwhere you -
<br />fine Teel ro the name d lhemnareark :asst rN X
<br />•OfNr do elrav poinlinp NOnn a.!wi
<br />In order to Vote In an Indian, me roan shown below must be poalmerxed or delNnM to the Board of Win,boax no Wier men the 25m day Delete the eleellan
<br />IDENTIFICATION FEQUIREUT
<br />I yell ab WI hnVa idnaerolltiaid el ieoil4`fvltY nurth+t(afa R}rtaGirglNi form DylnS, 8n]f.OVE hEVN IEnie'1<Olavge!n me Wuny ip Y!iN Yy ve r.6wrryPwelrtg, )Ya IflUil Rn'J, coils Ih!
<br />rppli.:Ji2,tiRepspy or ClRenghJ Yi6]pnJly il6nU(W:ILq.gRd WGY ale WIRn IIINfybd, b1rJC Sts ilAentcAll Wrin VoU,::for U& real. \Hnm]nl CdllmtflIaal5n5w$YJbI salsa
<br />8nd fiadaes. Ifyou Ta net Crovi "> 0a almmmivn Icpuea<d]D:ua, Yea uN a<rrquileaoprc ✓re IOloe!eabn aM1cNS colon you vJla for Ins f450me.
<br />G. Appueattion 10 t(egister to Vote( Print Information and Sign
<br />Bela"
<br />Office Lice Only
<br />Answer Ani,xi. Ol One Vered Increi afManaa"
<br />Vile he TV d ore on or before al"cdon 101 BYla
<br />YES NO
<br />No
<br />❑New RE ?ISaaoon
<br />VRN
<br />Filing No.
<br />❑ �. you yeas
<br />(- /r$t IIYOUOhxNadNOln rnoonvemeilher of lhmeouavuoex. do extcomWeB rhlelomt
<br />❑change of inrcrmallan
<br />Last Name
<br />Filet Name
<br />MiddlelMaiden Name Suffix
<br />Address whine you now live (Number and SucedRoad/Dorm)
<br />ApOLot
<br />Ciry
<br />Count/
<br />Salto
<br />NCZIP Code
<br />NG
<br />Address where you get your mat, 0 different TramAbove (Include ZIP
<br />Code)
<br />Provlous Name
<br />Previous Addicts. it you moved within the some county
<br />ApVLo[G'ty
<br />State NC ZIP Cado
<br />NO
<br />Data of Dinh
<br />Birthplace(Start)
<br />Gondar
<br />Telephone Number (Olece))
<br />❑Malt ❑Female
<br />EdmIclty(Any Race)
<br />Race
<br />I Attest, Under Penalty of Perjury, that:
<br />t�Hl:geniCl�filin0
<br />❑While El Asian
<br />I I'boll have been armidael of North Carolina, file county, precinct, mother
<br />❑ Not HispaniNLamo
<br />❑ Duck or African American
<br />ola%n dl]frlct for 30 day: before the non election in which l intend to veto.
<br />❑ Alnotiwn Indian or Alaska Nafive
<br />❑Two of More Races ❑Other
<br />Zleinigyeamold or will be ai this the oftbe nest general election, as indicated
<br />above.
<br />Political Party Affiliation
<br />❑ Democrat
<br />9.1 ]m a United Suiev tin :an, as indicated above,
<br />ID Number
<br />El Republican
<br />4, 1 am not ogiramd to wto not will l vote In any other county at state anal
<br />❑Llbedarien
<br />!ir swahi vi c".m, shoe h. ad
<br />nuhmieaion of thin voior ragenation form l am canceling any voter regielralion
<br />❑UnaBUiatbd
<br />cmuraum"er!an, mceaaL bi
<br />that l may have elsowham.
<br />❑Other Qualified
<br />❑Licenes No
<br />5. it i have been convicted of a tarany my righla of oilmen li, have boon restored
<br />uyu ra -m NCmw':s�!x cuss oe¢m]
<br />pally
<br />IHnVE READ AND UNDERSTAND THE CONTENTS OF THIS FGRM.
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<br />Warning:
<br />Nri J:nyaem:n vNe¢Irat e:ny
<br />❑SSN(Last 4 Digits)
<br />Ir yolwign ibis earl and Nnon It la be false, you soft by conmekd btu Cla]s liefmy.
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<br />1E]l no ND driver's license 0r 55th
<br />SgnaWta, paW:
<br />To Mail - Maisfen fold and seat
<br />
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