Voter Registration Application

Before completing this form, review the General, Application, and State specific instructions.

Are you a citizen of the United States of America? Yes No

□ □ This space for office use only.
Will you be 18 years old on or before election day? Yes No
If you checked "No" in response to either of these questions, do not complete form. □ □
(Please see state-specific instructions for rules regarding eligibility to register prior to age 18.)

□ Mr. □ Miss Last Name First Name Middle Name(s) □ II

□ Jr □
1 Ms. Lucio de Oliveira
III
□ Mrs.
□ Rodolpho □ Sr □ IV
Home Address Apt. or Lot # City/Town State Zip Code
2
3270 47th Street 3 Astoria New York 11103
Address Where You Get Your Mail If Different From Above City/Town State Zip Code
3
Date of Birth Telephone Number (optional) ID Number - (See item 6 in the instructions for your state)
4 04 12 1992
5 (929) 412-5323
Month Day Year 6
7
Choice of Party
(see item 7 in the instructions for your State)
8
Race or Ethnic Group
(see item 8 in the instructions for your State)
8269
I have reviewed my state's instructions and I swear/affirm that:
Q I am a United States citizen

Q I meet the eligibility requirements of my state and

9
subscribe to any oath required.
Q The information I have provided is true to the best of my
I Please sign full name (or put mark) A
I
knowledge under penalty of perjury. If I have provided false
information, I may be fined , imprisoned, or (if not a U.S.
citizen) deported from or refused entry to the United States.
Date:
I Month
z z Day Year
I
If you are registering to vote for the first time: please refer to the application instructions for information on
submitting copies of valid identification documents with this form.

Please fill out the sections below if they apply to you.

If this application is for a change of name, what was your name before you changed it?

Miss Last Name First Name Middle Name(s) II

I IB B I
A
Mr.
Mrs. Ms.

If you were registered before but this is the first time you are registering from the address in Box 2, what was your address where you were registered before?
Jr
Sr
III
IV

Street (or route and box number) Apt. or Lot # City/Town/County State Zip Code
B
I I I I
If you live in a rural area but do not have a street number, or if you have no address, please show on the map where you live.
■ Write in the names of the crossroads (or streets) nearest to where you live. NORTH 

_ I .______I_
■ Draw an X to show where you live.
■ Use a dot to show any schools, churches, stores, or other landmarks
near where you live, and write the name of the landmark.

Example
C
Route #2

● Grocery Store
Woodchuck Road
Public School ● X I I
If the applicant is unable to sign, who helped the applicant fill out this application? Give name, address and phone number (phone number optional).

Mail this application to the address provided for your State.

OMB Control No. 3265-0015
 FOR OFFICIAL USE ONLY

□
FIRST CLASS
STAMP
NECESSARY
FOR
MAILING

OMB Control No. 3265-0015

 General Instructions
Who Can Use this Application
If you are a U.S. citizen who lives or has an address
within the United States, you can use the application in
this booklet to:
• Register to vote in your State,
• Report a change of name to your voter registration
office,
• Report a change of address to your voter registration
office, or
• Register with a political party.

• A current and valid photo identification or

• A current utility bill, bank statement, government
check, paycheck or government document that
shows your name and address.
Voters may be exempt from this requirement if they
submit a COPY of this identification with their mail in
voter registration form. If you wish to submit a COPY,
please keep the following in mind:
• Your state may have additional identification re-
quirements which may mandate you show identi-
fication at the polling place even if you meet the
Federal proof of identification.
• Do not submit original documents with this appli-
cation, only COPIES.

If You Were Given this Application in a State

Agency or Public Office
If you have been given this application in a State
agency or public office, it is your choice to use the
application. If you decide to use this application to
register to vote, you can fill it out and leave it with
the State agency or public office. The application
will be submitted for you. Or, you can take it with
you to mail to the address listed under your State
in the State Instructions. You also may take it with
you to deliver in person to your local voter regis-
tration office.
• First, read the Application Instructions. These in- Note: The name and location of the State agency
structions will give you important information that or public office where you received the applica-
applies to everyone using this application. tion will remain confidential. It will not appear on
• Next, find your State under the State Instructions. your application. Also, if you decide not to use this
Use these instructions to fill out Boxes 6, 7, and application to register to vote, that decision will re-
refer to these instructions for information about main confidential. It will not affect the service you
voter eligibility and any oath required for Box 9. receive from the agency or office.
When to Register to Vote
Each State has its own deadline for registering to vote.
Check the deadline for your State on the last page of
this booklet.
OMB Control No. 3265-0015 1
 Application Instructions
Before flling out the body of the form, please answer the questions on the top of the form as to whether you are a
United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these
questions, you may not use this form to register to vote. However, state specifc instructions may provide additional
information on eligibility to register to vote prior to age 18.

Box 1 — Name Box 7 — Choice of Party

Put in this box your full name in this order — Last, In some States, you must register with a party if you
First, Middle. Do not use nicknames or initials. want to take part in that party’s primary election,
Note: If this application is for a change of name, please caucus, or convention. To fnd out if your State requires
tell us in Box A (on the bottom half of the form) your this, see item 7 in the instructions under your State.
full name before you changed it.
If you want to register with a party, print in the box the
Box 2 — Home Address full name of the party of your choice.
Put in this box your home address (legal address). Do
not put your mailing address here if it is diferent from If you do not want to register with a party, write “no
your home address. Do not use a post ofce box or party” or leave the box blank. Do not write in the word
rural route without a box number. Refer to state-specifc “independent” if you mean “no party,” because this
instructions for rules regarding use of route numbers. might be confused with the name of a political party in
your State.
Note: If you were registered before but this is the frst Note: If you do not register with a party, you can still
time you are registering from the address in Box 2, vote in general elections and nonpartisan (nonparty)
please tell us in Box B (on the bottom half of the form) primary elections.
the address where you were registered before. Please
give us as much of the address as you can remember. Box 8 — Race or Ethnic Group
A few States ask for your race or ethnic group, in order
Also Note: If you live in a rural area but do not have a to administer the Federal Voting Rights Act. To fnd
street address, or if you have no address, please show out if your State asks for this information, see item 8
where you live using the map in Box C (at the bottom in the instructions under your State. If so, put in Box 8
of the form). the choice that best describes you from the list below:
• American Indian or Alaskan Native
Box 3 — Mailing Address • Asian or Pacifc Islander
If you get your mail at an address that is diferent from
• Black, not of Hispanic Origin
the address in Box 2, put your mailing address in this
box. If you have no address in Box 2, you must write in • Hispanic
Box 3 an address where you can be reached by mail. • Multi-racial
• White, not of Hispanic Origin
Box 4 — Date of Birth • Other
Put in this box your date of birth in this order —
Month, Day, Year. Be careful not to use today’s date! Box 9 — Signature
Review the information in item 9 in the instructions
Box 5 — Telephone Number under your State. Before you sign or make your mark,
Most States ask for your telephone number in case make sure that:
there are questions about your application. However,
you do not have to fll in this box.
(1) You meet your State’s requirements,
Box 6 — ID Number and
Federal law requires that states collect from each (2) You understand all of Box 9.
registrant an identifcation number. You must refer to
your state's specifc instructions for item 6 regarding
information on what number is acceptable for your Finally, sign your full name or make your mark, and
state. If you have neither a drivers license nor a social print today’s date in this order — Month, Day, Year.
security number, please indicate this on the form and a If the applicant is unable to sign, put in Box D the
number will be assigned to you by your state. name, address, and telephone number (optional) of the
person who helped the applicant.

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 State Instructions
6.ID Number. You must provide a
driver's license or state identification New York North Carolina
number issued by the motor vehicle Updated: 01-12-2023
division of the taxation and revenue Updated: 08-22-2024
department or the last four digits of
Registration Deadline — 10 days Registration Deadline — Post-
your social security number. marked 25 days before the election
Computerized listings of limited before the election.
or received in the elections office or
voter registration information designated voter registration agency
(without social security numbers, 6.ID Number. Federal law requires
that you provide your driver’s li- site by 5:00 p.m. 25 days before the
codes used to identify agencies election.
where voters have registered, a cense number to register to vote. If
voter’s day and month of birth or, if you do not have a driver’s license
then you will have to provide at 6. ID Number. Provide your North
prohibited by voters, voters’
least the last four digits of your Carolina driver’s license number, or
telephone numbers) are available to North Carolina Department of
the general public, and are furnished social security number. If you have
neither, please write “NONE” on Motor Vehicles ID number. If you
upon request to incumbent election do not have a driver’s license, then
officeholders, candidates, political the form. A unique identifying
number will be assigned to you list the last four digits of your
parties, courts and non-profit orga- social security number. If you do
nizations promoting voter partici- by your State. 7.Choice of Party.
You must enroll with a party if you not have any of these identification
pation and registration, for political numbers, please write “NONE” on
purposes only. want to vote in that party’s prima-
ry election or caucus. the form. A unique identifying
7.Choice of Party. You must register number will be assigned to you for
with a party if you want to take part 8.Race or Ethnic Group. Leave
blank. voter registration purposes.
in that party’s primary election, cau- 7. Choice of Party. You may choose
cus, or convention. 9.Signature. To register in New
York you must: to affiliate with any political party
8.Race or Ethnic Group. Leave recognized in North Carolina. If you
blank. • be a citizen of the United States
indicate a political party that is not a
9.Signature. To register in New • be a resident of the county, or of
qualified party, or indicate no party,
Mexico you must: the City of New York, at least 30
you will be listed as “Unaffiliated.”
• be a citizen of the United States days before an election If you are unaffiliated, you may
• be a resident of the State of New • be 18 years old (you may choose to vote in any party’s
Mexico pre-register at 16 or 17 but cannot primary.
• be 18 years of age at the time of vote until you are 18) 8. Race or Ethnic Group. You are
the next election • not be in prison for a felony required to fill in this box.
• not currently be incarcerated as a conviction However, your application will not
result of a felony conviction. • not currently be judged incom- be rejected if you fail to do so. See
petent by order of a court of com- the list of choices under the
Mailing address: petent judicial authority Application Instructions for Box 8
Bureau of Elections • not claim the right to vote (on page 2).
325 Don Gaspar, Suite 300 elsewhere 9. Signature. To register in North
Santa Fe, NM 87503 Carolina you must:
Mailing address: • be a citizen of the United States
NYS Board of Elections • be a resident of North Carolina
40 North Pearl Street, Suite 5 and the county in which you live for
Albany, NY 12207-2729 at least 30 days prior to the election
• be at least 16 years of age and will
be 18 years of age by the day of the
next general election
• not be currently serving a felony
sentence (including any probation,
post-release supervision, or parole)

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