You can use this form to:

register to vote.

Voter Registration Form

• update your current registration if you have changed your address or name. Instructions: Please type or print clearly with a black pen.

1. Your last name, full legal first name, middle name or initial and any suffix such as Jr., Sr., etc.

2-4. House number, street, city and zip code for your current residence.

5-6. Mailing address only if it is different from your residence address, including post office box if applicable. County of residence.

7. The 2-digit number of the month, the day and the year you were born example: 04-24-45.

8. The city and state where you were born. If born outside the U.S., indicate city and/or country.

9-10. Social Security number and phone number are voluntary.

11. Previous address. Complete this section only if you are, or have been, registered to vote.

12. Complete only if you have changed your name since last registration. Put your former legal name in the first box; your former legal signature in the second box.

13. Signature. Your complete legal signature or mark should not touch surrounding lines or type. If signature is a mark, include name and address of the person who witnessed the mark. Date — 2-digit month, day and year.

To qualify to vote, you must be:

(1) a U.S. citizen;

(2) 18 years old on or before the general election day;

(3) a resident of Ohio for at least 30 days;

(4) registered to vote at least 30 days before election day.

or

Notice: Your registration change must be received or postmarked 30 days before an election at which you intend to vote. You will be notified by your county board of elections of the location where you vote.

Do you want to register to vote or update your current voter registration? Yes No

If you do not check a box, we will assume you choose not to register to vote.

Are you a U.S. citizen? This is an application for a

1. Last Name

FOLD HERE

☐ Yes

No If you answered NO, do not complete this form. New Registration Address Change

First Name

Name Change

Middle Name or Initial

Jr., II, etc.

2. House Number and Street (Enter new address if changed)

5. Additional Rural or Mailing Address (if necessary)

7. Birthdate (MO DAY YR) 8. Birthplace (City and State)

11. ADDRESS CHANGE ONLY PREVIOUS ADDRESS Previous House Number and Street

Apt. or Lot #

3.

City or Post Office

6.

County where you live

9 Social Security No. (voluntary) 10. Phone No. (voluntary)

4.

Zip Code

FOR BOARD USE ONLY SEC4010 (Rev. 1/99)

City, Village, Twp.

Ward

Previous City or Post Office

County

State

Precinct

12. CHANGE OF NAME ONLY

Former Legal Name

Former Signature

School Dist.

I declare under penalty of election falsification I am a citizen of the United States, will have lived in this state for 30 days immediately preceding the next election, and I will be at least 18 years of age at the time of the general election.

Cong. Dist.

Senate Dist.

13. Signature of Applicant→

House Dist.

Date

MO

DAY

YR

Information that will remain confidential and will be used only for voter registration purposes: 1) the office where you submit your voter registration application or 2) the fact that you have declined to register. WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.