Voter Registration Form

To qualify to vote, you must be:

(1) a U.S. citizen;

Please read instructions carefully.

(2) 18 years old on or before the next general election; (3) a resident of Ohio for at least 30 days immediately

before election day:

(4) registered to vote at least 30 days

before election day.

Use this form to register to vote or update a current Ohio registration if you have changed your address or name.

NOTICE: Your registration or 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. If you do not receive a notice prior to election day, call your county board of elections.

Lines 1 and 2 are required by law. If you do not answer both of the questions, your registration will not be processed.

Registering in person

If you have a current valid Ohio driver's license, you must provide that number on line 10. If you do not have an Ohio driver's license, you must provide the last four digits of your social security number on line 10.

Registering by mail

If you register by mail and do not provide either a current Ohio driver's license number or the last four digits of your social security number, please enclose a copy of one of the following with your registration application:

• Current valid photo identification card showing your

name: or

• Current utility bill, bank statement, paycheck,

government check or government document showing

your name and address.

If you register by mail and do not provide one of the above at the time of submitting your registration application, you must provide one of the items when you vote for the first time.

Your Signature

Your registration cannot be processed without your signature. On line 14. your completed legal signature or mark should not touch surrounding lines of type. If signature is a mark, include name and address of the person who witnessed the mark beneath the signature line.

Please type or print clearly with a black pen.

FOLD HERE

1. Are you a U.S. citizen?

Yes

No

Yes

No

2. Will you be 18 years of age on or before the next general election?

If you answered NO to either of the questions, do not complete this form.

3 Last Name

First Name

Middle Name or Initial

Jr. II. etc.

4 House Number and Street (Enter new address if changed)

Apt or Lot #

5 City or Post Office

7 Additional Rural or Mailing Address (if necessary)

8 County where you live

9 Birthdate (MO DAY YR.

10 Ohio driver's license No OR last 4 digits of Social Security No (required) 11 Phone No (voluntary)

12 ADDRESS CHANGE ONLY PREVIOUS ADDRESS Previous House Number and Street

Previous City or Post Office

13 CHANGE OF NAME ONLY

Former Legal Name

State

County

Former Signature

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

14

Signature of Applicant →

Date

MO

DAY

YR

WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.

6

Zip Code

FOR BOARD USE ONLY

SEC4010 (Rev 10/03)

City Village. Twp

Ward

Precinct

School Dist

Cong Dist

Senate Dist

House Dist