voter registration form

3b Pennyslvania Driver’s License OR Social Security Number: You
must supply a PA Driver’s License Number if you have one. If you do
not have a PA Driver’s License Number, you must supply the last four
digits of your Social Security Number. If you do not have a Social
Security Number, please check the box to the right of 3b.
4a Address of Residence: Fill in your complete address of residence.
P.O. boxes may not be used here unless there is no physical address.
Print street address, city and zip code. (If the residence is only a portion
of the house, include the location of the room, apartment or
floor which is occupied.) 4b Although providing your telephone
number is optional, it is a quick and easy way for your county to
contact you if there is missing information on your registration form.
In Box 4c fill in the name of the municipality (city, borough or
township) and county where you live. Use the map in the box below if
you cannot otherwise identify your address.
Prior Registration: If you were registered before, fill in the name used
on your previous registration in Box 8a and address, county and year of
previous registration in Box 8b.
Name of Assistant: If the applicant is unable to complete or sign the
application, the person who assisted the applicant must provide his or her
name, address and signature.
Registration Declaration: You must be a citizen of the United States to
register to vote in the Commonwealth of Pennsylvania. Please read the
registration declaration carefully. You must sign and print your name and
date the application.
If you were assigned at Voter Identification Number, which appears on
your Voter Identification Card, place that Identification Number, if
available here. If you are applying to register to vote for the first time,
leave this box blank.
If you require assistance when voting, you must check the box and provide
the reason.
PENNSYLVANIA VOTER REGISTRATION APPLICATION
1
2
3
a
Are you a citizen of the United States of America?
Will you be 18 years of age on or before election day?
New Registration
Change of Name
Change of Address
M Last Name
4
}
If you checked “No” in response to either of
these questions, do not complete this form.
I am a Federal or State employee and wish to retain my voting
residence in the county where I last resided.
Change of Party
Middle Name/Initial
Jr Sr II III IV
(circle if applicable)
F
I DO NOT have a PA Driver’s License
or Social Security Number.
If no PA DL #, Place
SS# (last 4 digits) here:
if you have one:
Address of residence, include street and city (Use map above if no street number or name) (If only P.O. box, see above)
a
4
No
No
First Name
PA Driver’s
3 Place
License (DL) # here
b
Yes
Yes
Municipality where you live
County where you live
c
5
Apt #
4
State Zip Code
PA
Mailing Address (if different than address of residence)
b
Telephone Number (Optional)
(
City
)
State Zip Code
Address of previous registration (include street and city)
6 Date of Birth
7 Race (Optional) 8 Name on previous registration
a
/ /
8
party do you wish to register? You must register with a party if you want to take part in that party’s primary. b County of previous registration Year of previous registration
9 In which
Democratic
Republican
Libertarian
No affiliation
Other
Name and signature of person who assisted in the completion of this application
Place signatue with full name (or mark) below
(Please see Penalty for Falsifying Declaration.)
10 Address
DECLARE THAT:
11 I(1)HEREBY
On the day of the next election I will have been a United States citizen
for at least one month. I will be at least 18 years of age, and I will have
resided in Pennsylvania and in my election district for at least 30 days;
(2) I am legally qualified to vote.
X
AND I HEREBY AFFIRM THAT the information I have provided in this
Print Your Name Below
registration declaration is true. I understand that this registration declaration will
be accepted for all purposes as the equivalent of an affidavit; and if the registration
contains a materially false statement, I will be subject to penalties for perjury.
Date:
/
/
Voter Identification Number
- not necessary if you are registering to vote for the first time
12 (Ifor ifavailable
you do not know your number.)
you require assistance
13 Do
when voting?
Yes
Reason for assistance:
No
ADDRESSES OF COUNTY VOTER REGISTRATION OFFICES
To mail this application, write the address of the County Voter Registration Office in the proper area on the reverse side of this form.
ADAMS COUNTY
111-117 BALTIMORE ST
GETTYSBURG PA 17325-2312
(717) 337-9832
BUCKS COUNTY
55 E COURT ST
DOYLESTOWN PA 18901-4318
(215) 348-6163
ALLEGHENY COUNTY
542 FORBES ST STE 609
P IT T S B U R G H PA 15219-29 13
(412) 350-4500
BUTLER COUNTY
PO BOX 1208
BUTLER PA 16003-1208
(724) 284-5308
ARMSTRONG COUNTY
450 E. MARKET ST, STE 207
KITTANNING PA 16201
(724) 548-3222
BEAVER COUNTY
810 THIRD ST
BEAVER PA 15009
(724) 728-5700
CAMBRIA COUNTY
200 S CENTER ST
EBENSBURG PA 15931
(814) 472-1464
CHESTER COUNTY
601 WESTTOWN RD STE 150
PO BOX 2747
WEST CHESTER PA 19380-0990
BEDFORD COUNTY
200 SOUTH JULIANA ST 3RD FLOOR (610) 344-6410
BEDFORD PA 15522
(814) 623-4807
CLARION COUNTY
421 MAIN ST STE 19
BERKS COUNTY
CLARION PA 16214-1093
633 COURT ST
(814) 226-4000 EXT 2205
READING PA 19601
(610) 478-6490
CLEARFIELD COUNTY
230 E MARKET ST STE 108
BLAIR COUNTY
CLEARFIELD PA 16830
423 ALLEGHENY ST STE 043
(814) 765-2641 EXT 5996
HOLLIDAYSBURG PA 16648-2022
(814) 693-3150
CLINTON COUNTY
BRADFORD COUNTY
232 E MAIN ST GARDEN BLDG 3RD FL
301 MAIN ST
LOCK HAVEN PA 17745-1385
TOWANDA PA 18848-1878
(570) 893-4019
(570) 265-1717
COLUMBIA COUNTY
35 W MAIN ST PO BOX 380
BLOOMSBURG PA 17815-0380
(570) 389-5640
GREENE COUNTY
93 E HIGH ST RM 102
WAYNESBURG PA 15370
(724) 852-5230
LEBANON COUNTY
400 S 8TH ST
LEBANON PA 17042-6794
(717) 274-2801 EXT 4428
NORTHUMBERLAND COUNTY
609 MARKET ST
SUNBURY PA 17801-2360
(570) 988-4208
UNION COUNTY
155 N 15TH ST
LEWISBURG PA 17837-8822
(570) 524-8681
CRAWFORD COUNTY
903 DIAMOND PARK
MEADVILLE PA 16335-2678
(814) 333-7306
HUNTINGDON COUNTY
223 PENN ST COURTHOUSE
HUNTINGDON PA 16652-1486
(814) 643-3091
LEHIGH COUNTY
17 S 7TH ST
ALLENTOWN PA 18101-2401
(610) 782-3194
PERRY COUNTY
PO BOX 37
NEW BLOOMFIELD PA 17068-0037
(717) 582-2131 EXT 4110
VENANGO COUNTY
1174 ELK ST PO BOX 831
FRANKLIN PA 16323-0831
(814) 432-9514
CUMBERLAND COUNTY
310 ALLEN RD
CARLISLE PA 17013-3044
(717) 240-6385
INDIANA COUNTY
825 PHILADELPHIA ST
INDIANA PA 15701-3934
(724) 465-3852
MERCER COUNTY
5 COURTHOUSE
MERCER PA 16137-1227
(724) 662-3800 EXT 2240
PHILADELPHIA COUNTY
520 N DELAWARE AVE 5TH FL
PHILADELPHIA PA 19123-4295
(215) 686-1591
WARREN COUNTY
204 4TH AVE
WARREN PA 16365-2399
(814) 728-3406
DAUPHIN COUNTY
PO BOX 1295
HARRISBURG PA 17108-1295
(717) 780-6360
JEFFERSON COUNTY
155 MAIN ST JEFFERSON PLACE
BROOKVILLE PA 15825-1269
(814) 849-1605
MIFFLIN COUNTY
20 N WAYNE ST
LEWISTOWN PA 17044
(717) 248-6571
PIKE COUNTY
506 BROAD ST
MILFORD PA 18337-1535
(570) 296-3426
WASHINGTON COUNTY
100 W BEAU ST RM 206
WASHINGTON PA 15301
(724) 228-6750
DELAWARE COUNTY
GOVT CENTER BLDG 201 W FRONT ST
MEDIA PA 19063-2728
(610) 891-4659
JUNIATA COUNTY
BRIDGE ST PO BOX 68
MIFFLINTOWN PA 17059
(717) 436-7706
MONROE COUNTY
ONE QUAKER PLAZA RM 105
STROUDSBURG PA 18360-2170
(570) 517-3165
POTTER COUNTY
1 NORTH MAIN ST
COUDERSPORT PA 16915
(814) 274-8467
WAYNE COUNTY
925 COURT ST
HONESDALE PA 18431-1996
(570) 253-5978
ELK COUNTY
300 CENTER ST PO BOX 448
RIDGWAY PA 15853-0448
(814) 776-5337
LACKAWANNA COUNTY
135 JEFFERSON AVE STE 100
SCRANTON PA 18503
(570) 963-6737
MONTGOMERY COUNTY
COURTHOUSE PO BOX 311
NORRISTOWN PA 19404-0311
(610) 278-3280
SULLIVAN COUNTY
PO BOX 157
LAPORTE PA 18626-0157
(570) 946-5201
WESTMORELAND COUNTY
2 N MAIN ST STE 109
GREENSBURG PA 15601
(724) 830-3150
ERIE COUNTY
140 W 6TH ST RM 105
ERIE PA 16501-1096
(814) 451-6276
LANCASTER COUNTY
150 NORTH QUEEN ST STE 102
LANCASTER PA 17603-3562
(717) 299-8293
MONTOUR COUNTY
29 MILL ST
DANVILLE PA 17821
(570) 271-3000
SUSQUEHANNA COUNTY
PO BOX 218 MAPLE ST
MONTROSE PA 18801-0218
(570) 278-4600 EXT 220
WYOMING COUNTY
1 COURTHOUSE SQ
TUNKHANNOCK PA 18657-1216
(570) 996-2226
FULTON COUNTY
116 W MARKET ST STE 203
MCCONNELLSBURG PA 17233
(717) 485-3691
LAWRENCE COUNTY
430 COURT ST
NEW CASTLE PA 16101-3593
(724) 656-2161
NORTHAMPTON COUNTY
670 WOLF AVE
E A S T O N PA 18042- 4343
(610) 559-3055
TIOGA COUNTY
118 MAIN ST
WELLSBORO PA 16901-0589
(570) 723-8230
YORK COUNTY
28 EAST MARKET ST
YORK PA 17401-1579
(717) 771-9604