NORTH CAROLINA VOTER REGISTRATION APPLICATION
Please use black or blue ink and print legibly.

1

Are you a citizen of the United States of America?

Yes

06w

Date Received

No Will you be at least 18 years of age on or before election day?

IF YOU CHECKED "NO" IN RESPONSE TO THIS QUESTION,
DO NOT SUBMIT THIS FORM.

2

FOR OFFICE USE ONLY

No

Are you at least 16 years of age and understand that you must
Yes
No be 18 years of age on or before election day to vote?
IF YOU CHECKED "NO" IN RESPONSE TO BOTH OF THESE QUESTIONS
ABOVE, DO NOT SUBMIT THIS FORM.

Last Name (Required)

First Name (Required)
M
M
D
D

Y

Y

Middle Name (Required)

Y

Y

Sr

II

III

County of Birth

Jr

Date of Birth MMDDYYYY (Required)

If you know your NC Voter Registration Number, please enter it here:

3

Yes

IV

V

State of Birth

Do you have a NC Driver's License or DMV-issued identification card? If yes, provide the number.

Yes

No

If you do not have a NC DMV-issued license or ID card, do you have a Social Security Number? If yes, provide the last 4 digits.

Yes

No

XXX

-

XX

-

RESIDENTIAL ADDRESS INFORMATION (STREET ADDRESS WHERE YOU LIVE) - No P.O. Boxes or Rural Routes

4

Street Address where you live (Required)

Apartment, Lot, or Unit Number

NC
City (Required)

State

Have you lived here for 30 days or more?

County

Yes

Zip Code

No
If "No," date moved? MMDDYYYY

Phone (Optional)

MAP/DIAGRAM

MAILING ADDRESS

If you do not have a street address, draw a map of where you reside.
Please include roads and landmarks.

5

Mailing Address (If different from your residential address)

State

City

6

GENDER

RACE

Zip Code

POLITICAL PARTY AFFILIATION

ETHNICITY

Female

African American/
Black

American Indian/
Alaska Native

Male

Asian

Multiracial

White

Other

Hispanic/Latino

Democrat

Republican

Not Hispanic/
Latino

Unaffiliated

Other

Libertarian

If you indicate a political party that is not currently qualified or you do not indicate a choice, you will be listed as "Unaffiliated."

PREVIOUS REGISTRATION (Name & Address used for your last voter registration - If applicable)

7

Last Name used in Previous Registration

First Name

Previous Address

State

Previous City