For Official Use Only

Please mail this application to:

REGISTRAR OF VOTERS


1

Application Type: 

Continue below to complete application.
2
Last Name: Include Suffix if any
(Jr, Sr, III)

First Name

Middle Name (If Any)

Former Name (If Any)

3
Residence Address: Street Address and Apartment Number. If none, describe where you live. (Do not include P.O. Box, Rural Rt. or Business Address)
City

County

State

Zip Code

4
Mailing Address: Street Address and Apartment Number (If mail cannot be delivered to your residence address.)
City

State

Zip Code

5
City and County of Former Residence in Texas

6
Date of Birth: (mm/dd/yyyy)

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7
Gender (Optional)

8
Telephone Number, Include Area Code (Optional)

 
9
Texas Driver's License No. or Texas Personal I.D. No.
(Issued by the Department of Public Safety)



If no Texas Driver's License or Personal Identification, give last 4 digits of your Social Security Number


10
I understand that giving false information to procure a voter registration is perjury, and a crime under state and federal law. Conviction of this crime may result in imprisonment up to 180 days, a fine up to $2,000, or both. Please read all three statements to affirm before signing.
X
_______ / _______ / _______
Date
Signature of Applicant or Agent and Relationship to Applicant or Printed Name of Applicant if Signed by Witness and Date.