North Carolina Voter Registration Application

The North Carolina Voter Registration Application is a form that has to be used for registering to vote in your county of residence within the State of North Carolina. You are required to provide updated name, party affiliation, and address in the form you are submitting.

Extracted Text for Proper Search

version102013	
06w	NORTH CAROLINA VOTER REGISTRATION APPLICATIONPlease use black ink and print legibly.	
1	Are you a citizen of the United States of America?	 Yes	 No	Will you be at least 18 years of age on or before election day?	
IF YOU CHECKED "NO" IN  RESPONSE TO THIS QUESTION,  DO NOT SUBMIT THIS FORM. 	IF YOU CHECKED "NO" IN RESPONSE TO THIS QUESTION,  DO NOT SUBMIT THIS FORM.  	
2	
 Last Name (Required)
 First Name (Required)
Middle Name (Required)	
 Jr	 Sr	 II	
 III	 IV	 V	
3	
 Date of Birth MMDDYYYY (Required)	 State of Birth/Country of Birth	
 If you know your NC Voter Registration Number, enter it below.
 If you have a NC drivers license or non-operators ID card, enter the nu\
mber below.
 Enter the last 4 digits of your SSN.	Check here if you do not have a NC 
drivers license, ID card, or a SSN.	
RESIDENTIAL ADDRESS INFORMATION - No P.O. Boxes or Rural Routes
4	
 Street Address where you live  (Required)	 Apartment, Lot, or Unit Number	
 City (Required)	 State	 Zip Code	
County	Have you lived here 
for 30 days or more?	Yes	No	 If "No," date moved? MMDDYYYY	 Phone (Optional)	
MAP/DIAGRAM If you do not have a street address, draw  a map of where you reside.  
Please include roads and landmarks.	
NC	
MAILING ADDRESS
5	 Mailing Address (If different from your residential address)
Mailing Address Line 2
 City	 State	 Zip Code	
6	GENDER 	RACE	ETHNICITY 	POLITICAL PARTY AFFILIATION	
 Female
 Male	
 African American/ 
 Black
 Asian
 White	
 American Indian/ 
 Alaska Native
 Multiracial
 Other	
 Hispanic/Latino
 Not Hispanic/ Latino	
 Democrat	 Republican	 Libertarian	
 Unaffiliated	 Other
If you indicate a political party that is not currently qualified, or 
you do not indicate a choice, you will be listed as "Unaffiliated."	
PREVIOUS VOTER REGISTRATION (This information will be used to cancel your previous voter registrati\
on in another county or state.)
7	
 Last Name used in Previous Registration	 First Name used in Previous Registration	
 Previous Address	Previous County	
 Previous City	 Previous State	 Previous Zip Code	
I attest, under penalty of perjury, that in addition to having read and understood the contents of this fo\
rm, that: 
· I am a United States citizen, as indicated above;  
· I am at least 18 years of age, or will be by the date of the genera\
l election;  
· I shall have been a resident of North Carolina, this county, and pr\
ecinct for 30 days before the election in which I intend to vote;  
· I will not vote in any other county or state after submission of th\
is form and if I am registered elsewhere, I am canceling that registrati\
on at this time;  and  
· I have not been convicted of a felony, or if I have been convicted \
of a felony, I have completed my sentence, including any probation or pa\
role. 
  (Citizenship and voting rights are automatically restored upon comple\
tion of the sentence. No special document is needed.) 
  
  
  
 	
Signature (Required)	Date	X	
Fraudulently  or falsely  completing  this 
form  is a Class  I Felony  under Chapter 
163 of the NC General Statutes.	
 Yes	 No