Texas Voter Registration Application Page 2
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1
2Texas Voter Registration Application
For Official Use Only
Print
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Prescribed by the Office of the Secretary of State
VR17.09E.I3
Please complete sections by printing LEGIBLY. If you have any questions about how to fill out this application,
please call your local voter registrar or the Secretary of State's Office toll free at 1-800-252-VOTE(8683), TDD
1-800-735-2989,
1
These Questions Must Be Completed Before Proceeding
Check one
New Application
Change of Address, Name,
Request for a Replacement Card
or Other Information
Are you a United States Citizen?
Yes
No
Will you be 18 years of age on or before election day?
Yes
No
If you checked 'No' in response to either of the above, do not complete this form.
Are you interested in serving as an election worker?
Yes
No
2
Last Name
First Name
Middle Name
Former Name
Include Suffix if any
(if any)
(If any)
(Jr, Sr, III)
3
Residence Address:
City
Street Address and Apartment Number. If none,
TEXAS
describe where you live.
(Do not include P.O. Box, Rural Rt. or Business Address)
Zip Code
Mailing Address:
City
4
State
Street Address and Apartment Number. (If mail
cannot be delivered to your residence address.)
Zip Code
5
6
7
Telephone Number
Date of Birth:
Gender (Optional)
(mm/dd/yyyy)
(Optional)
Include Area Code
Male
(
)
Female
8
Texas Driver's License No. or Texas Personal
If no Texas Driver's License or Personal Identification,
I.D. No.
(Issued by the Department of Public Safety)
give last 4 digits of your Social Security Number
xxx-xx-
I have not been issued a Texas Driver's License/Personal Identification Number or
Social Security Number.
9
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.
• I am a resident of this county and a U.S. citizen;
• I have not been finally convicted of a felony, or if a felon, I have completed all of my punishment
including any term of incarceration, parole, supervision, period of probation, or I have been
pardoned; and
• I have not been determined by a final judgment of a court exercising probate jurisdiction to
be totally mentally incapacitated or partially mentally incapacitated without the right to vote.
X
/
/
Date
Signature of Applicant or Agent and Relationship to Applicant or Printed Name of Applicant if Signed by Witness and Date.
VR17.09EI3.indd 2
8/14/2009 10:12:25 AM
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