Arkansas Voter Registration Application

Voting in the State of Arkansas requires the voter to be registered. To register for voting, you are required to complete and send the following form.

Extracted Text for Proper Search

Plea se comp letethesections below if:
•You wereprev ious lyregis teredin an other county or state, or
•Youwish tochange the name or address onyour curre ntregistrati on.	
ARKANSA SVOT ER REGISTRA TIONAPPLICA TION	
Checkall tha tappl y:____Thisis anew registrati on.
____ Thisis aname change.
____Thisis an address change.
____ Thisis aparty change .
1	
Mr.
Mr s.
Mi ss
Ms.	Last Name	Jr. Sr.
II.III. IV .	First Name	Middle Name	
2	
Apt. or Lot #	City/Town	State	
PLE ASE PRI NT ANDUSE BLACK INK TOCOMPLETE	
\f
4	Da teofBir th	_________	\b________ _	\b____ _____	M onth Day Year	5	
(A) Are you acitizen ofthe Unit edStates ofAmerica andanArkan sasresident?
�Yes �No
(B) Willyou beeighte en(\f8) years ofage orolder onorbef ore election day?
�Yes �No
(C)	
Areyou presen tly adju dg ed me nta lly incompet entby acourt ofcom petent jurisdicti on?�Yes �No
(D)Have you ever been convic ted of a felony without	yoursent ence having been
dischargedorpardoned?
� Yes �No
Ifyou checked No in response toeither questionsAor B, do not complete thisform.
Ifyou checked Yes inresponse toeither questionsCor D, do not com plete thisform.	
A	
Mr.
Mrs.
M iss
M s.	First Name	Middl eName(s)	
B	
Previo usHouse Number andStreet Name	Apt.or Lot#	City orTown	State	
C	
•W rite in the name sof the crossroads (orstreet s)neare stwhere youlive.
•Dra wan “X” toshow where youlive.
•Use adot toshow anyschoo ls,churches, storesorother landmarks near
where you liveand write thename ofthe land mark .	
•P ubl icSch ool	
X	
•G ro cery
Stor e
Woodchu ckRoad	
Route#2	
Rev. 6\b11	
NORTH	
Of fice Use Only	
Address Where YouLive (See Section“C” Belo w)(Rur aladdresse smu stdraw map.)	Zip Code	
Address Where YouReceive MailIfDifferent FromAbove	City/Town	St ate	Zip Code	
Home &Work Phone Number s(Opti onal)
(H) (W)	
IDNumb er\bC he ck the app lica ble box andpr ovide theappropria te number.�	Ar ka nsa s	Driv erʼ slice nse number	___ __ __ _____ ____ _______ _____________	�	If you donot have adrive rʼslice nseprovi dethe la st 4 di gits of soci al
se curi ty numbe r____ _____ _____ _______ ____ ____	
�	I have neit her adriv erʼs licens enor socia lsecu rity number .	
9	
Date:	____ _________	\b______ _____ __	\b____ ___ ______	Mo nth Day Yea r	
Have youeve r vo ted inafeder alelec tion inthis State ?	�Yes �No	
If appl icant isunabl eto sign his\bher name, provide name, ad dre ss an d
phone numberofthe per son prov iding assistance:
Name ____________ _______ ____ _Add res s:__ _______ __ ___ _______ ___
City:_ ______ _______ _____ Sta te :_ __ __ Ph one #:__ ______ _____________	
8	
M AIL RE\b IST RA\f TS:P LE ASE SEE SECT IO\f D.	
Zip Code	
If you live inarural areabutdonot have ahouse orstreet numb er,orif
you hav eno address, plea se show onthe map whereyo ulive.
Ex amp le	D	
ID EN TIFICATIO NREQ UIR EMENTS	
IMPO RTAN T:If your voter registrati onapplica tion
form issubmit ted bymail andyouareregiste ringfor
the first tim e, and youdonot have avalid Arkansas
drive r's lic en se nu mber or soc ial sec urity
numbe r	
,in or der toavoid the additional identification	
re qui rem ent supon voting forthe fir st time you
m us tsubm itwith the mail ed regis trati on for m:(a) a
cur ren t	
and validphot oidentifica tion;or(b) acopy
of acurren tut ilit ybill, bank state ment, governmen t
check,paycheck, orother government document
that shows your nam eand addres s.	
Apt. or Lot #	
County
County	
6	Par ty Affiliation (Optional)	
The inf orm atio n Iha ve pro vid ed is tr ue toth e best ofmykno wled ge .Id o no tclaim therig ht
to vo te in anoth ercou nty orsta te. IfIhave pro vided fal se in fo rm atio n, Ima ybe sub ject to
a fin e of up to $\f0,00 0and/o rim prison mentof up to\f0 yea rs un de rstate and fe de rallaw s.
11
Si gna ture of ele cto r\b P le ase signfull nam eor pu t m ar k.	
10	
Jr. Sr.
II.III. IV.	
Assig ned ID	
Da teof Birth	__ ___ ____	\b__ _______	\b__ ____ ___	Mo nth Day Year	
Agen cy Code (F or O ffi cial Use On ly)	
Previo usLast Name	
7	E\bmai lAd dress	(Optional)

Deadline Infor mation
Toqua lify to vo teinthe next elect ion,you must apply to regist erto vote \f0days before theelection .
If you mail this form, itmust bepost mark ed by that date. You mayalso prese nt itto avoter
re gistr ation	
agenc yrepres entative bythat date . If you miss th e deadline youwillnot be registered
intim eto vote in that election. Pleasedonʼt delay. Make sureyo ur vote counts.	
If you arequali fied and thein fo rmatio non you rform isco mple te,you willbe notified ofyour
voting precinct byyour localC oun tyClerk.
To Mail
Fold form onmiddle perfora tion,remove plastic strip,seal atbottom, stamp and mai l.	
Quest ions?
Call your local County Cl erk
or
Ar kansas Secretary ofState
Mark Martin
El ecti ons Division –Vot erServices
1-800- 482-1127	
Contact your County Clerkif yo uhave notrec eive dconfi rmation ofthis applic ation
within tw o weeks .	
Fro m:
________________________
________________________
________________________	
Arkan sasSecret aryof St ate
AT TN: VoterReg istrat ion
P . O. Box81 11
Litt le Ro ck, Arkansas 7220\f-8111	
Fi rst
Class
Postage
R equi red