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State of Alaska Voter Registration Application

You are required to complete the State of Alaska Voter Registration Application and send it by email or fax to one of the offices stated at the application forms.

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C03 (Rev. 	02/29	/2016	) 	
STATE OF ALASKA VOTE	R REGISTRATION APPLI	CATION	 	
Refer to instructions on the reverse side for specific information and identification requirements.	 	
Please print clearly in blue or black 	ink.	  	
1.	 
 	
You MUST complete this section for registration:	 	
 Yes	 	
 Yes	 	
 No	 	
 No	 	
I am a citizen of the United States.	 	
I am at least 18 years old or will be within 90 days of completing this application.	 	
 	If you checked NO to either question, do not complete 	this form as you are not eligible to register to 	
vote.	 	
2.	 	Last Name	 	First Name	 	Middle Initial	 	Suffix	 	
3.	 	Former Name	: (If your name has changed)	 	
4.	 	You 	MUST	 provide the 	Alaska	 residence address where you claim residency. Do not use PO, PSC, HC or RR.	 	
 	 	 	 	 	 	 	 	 	
Alaska	 	
 	
House No.	  	Street Name	 	 	Apt No.	 	 	City	 	 	State	 	 	
 	* Keep my residence address confidential	. (Your mailing address in section 5 must be DIFFERENT from your 	
residence address in section 4 to remain confidential.)	 	
5. 	Mailing Address:	 	 	7.	 	 I am a 	voter with a disability and would like 	
information on alternative voting methods.	 	
 	 	 	8.	 	 I am interested in serving as an election official. 	(Provide your phone number and/or email address in section 12.)	 	
 	 	 	9.	 Daytime Phone No.:	  	 	
 	 	Evening Phone 	No.:	 	 	 	
6.	 	*AK	 Voter Number:	  	 	 	Email Address:	 	 	 	 	(If known)	 	 	 	 	 	 	
10.	 	Identifiers 	– You	 MUST 	provide at least one:	 	
 
 	*SSN or Last 4 of SSN:	  
 	/  	/  	*Alaska Driver’s License 
or State ID Number	 	 	 	 	 	 	 	 	 	
 	 I have not been issued a Social Security Number, Alaska Driver’s License or State ID number.	 	 	
11.	 	You	 MUST 	provide:	 	12.	 	Gender	 	 Male	 	 Female	 	 	*Date of Birth	 	 	/  	/  	 	 	
 	 	Month	 	 	Day	 	 	Year	 	 	 	 	
13.	 	Political Affiliation	 For 	political affiliation choices in Alaska,	 see 	instruction	 number 	5 on the reverse side.	 	 	
 	Write political affiliation:	 	 	 	
 	
14	 	I am registered to vote in another state, cancel my registration in:	 	 	
 	City:	 	 	 State:	 	 	 County:	 	 	 Zip:	 	 	 	
 	 	 	  	 	  	 	  	 	 	
Voter Certificate.  Read and Sign:  	I certify, under penalty of perjury, that the above information I provided on 	
this document is true and correct.  I am not registered to vote in another state, or I have provided information to 
cancel that registration.  I further certify that I am a resident of Alaska and I have not been convicted of a felony, or 
having been so convicted, have been unconditionally discharged from incarceration, probation and/or parole.	 	
 
WARNING	:  If you provide 	false information on this application you can be convicted of a misdemeanor AS 15.56.050.	 	 
*SIGNATURE:	 	 	 	DATE:	 	 	
 	
Your signature must be a handwritten signature.  A typed or digital signature is not valid.	 	
Registrar/Agency/Official 	– Check ID and 	complete this section	 	
 	 	 	
OR 	
 	 	
Registrar Name	 	 	Voter No or SSN	 	Agency Name	 	 	
*Items are kept confidential by the Division of Elections and are not available for public inspection except that confidentia	l addresses may 	be released to government agencies or during election processes as set out in state law.

State of Alaska 	- Divis	ion of Elections	 	
Voter Registration Application	 	  
To register to vote in Alaska you must be a U.S. Citizen, a resident of Alaska, and at least 18 years old or will be 
18 years old within 90 days of completing this application.	 	
Initial registration or 	registration changes must be made at least 30 days prior to an election.  Once your application is 	
processed, a notice will be mailed to you within 3 to 4 weeks.	 	
1. When Completing This Application You 	MUST	 Provide:	 	
 Alaska	 Residence Address Where You Claim 	Residency	 – A complete physical residence address	 in Alaska	 must 	
be included on your application.  The residence address you provide will be used to assign your voter record to a voting 
district and precinct. Your application will be 	denied 	if you 	do not p	rovide an Alaska residence address or 	you provide a 	
PO Box, HC No. and Box, PSC Box, Rural Route No., Commercial Address or Mail Stop Address 	or a resid	ence address 	
outside of Alaska o	n Line 4 of the application.	 	
If your resid	ence has been assigned a stree	t name and house 	number, provide 	this information or 	indicate exactly 	
where you live such as, highway name and milepost number, boat harbor, pier and slip number, subdivision name with 
lot and block or trailer park name and space number.  If you live in ru	ral Alaska, you may provide the community name 	
as your residence address.	 	
If you have a 	different	 mailing address 	than your residence address, you may choose to 	keep	 your residence address 	
confidential.  Confidential addresses are not released to the gener	al public, but may be released to government 	
agencies or during election processes as set out in state law. 	 	
If you are temporarily out of state and have intent to return	, you may maintain your Alaska residence as it appears on 	
your current record.  If you	 provide a new residence address, it must be within Alaska.	 Active military and military 	
spouses are exempt from intent requirement	. 	
 Proof of Identity 	– Your identity must be verified. If you have been issued a Social Security number, Alaska Driver’s 	
Licen	se, or Alaska State ID card, you MUST provide at least one number on Line 	10	 of the application.  If you have 	
never been issued one of the identification numbers, 	please	 indicate so by checking the box 	on	 Line 	10	. 	
 Date of Birth	 – You MUST provide your date	 of birth.	 	
2. Are you submitting this application by mail	, by fax	, or email	?  If so, and if you are not already registered to vote 	
in Alaska, your identity must be verified either at the time you register or the first time you vote.  If you would like to 
ens	ure that your identity is verified at the time you register, submit a copy of one of the below:	 	
 Current and valid photo identification	 	
 Driver’s license	 	
 Passport	 	
 State identification card	 	
 Birth certificate	 	
 Hunting and Fishing license	 	
3. Are you registering from outside the State of Alaska?  	If so, you must provide proof of Alaska re	sidency, such as a 	
copy of your 	current 	Alaska driver's license/ID, 	current 	Alaska hunting or fishing license, student loan or college tuition 	
documents showin	g Alaska as state of residence, 	proof of employment in Alaska	 that indicates the date on which you 	
were employed, 	military leave and earnings statement that identifies Alaska as the state of legal 	residence	 or other 	
documentation that supports your claim a	s an Alaska resident	.  If you do not provide proof of Alaska res	idency, your 	
app	lication will not be processed.	 	
4. Have you been convicted of a felony?  	If so, you may register to vote only if you have been unconditionally 	
discharged.  Provide a copy of your 	discharge papers with this application if available.	 	
5. Political	 Affiliation.	 Write you	r political affiliation. Recognized political parties are 	parties	 who have gained	 recognized	 	
political party status 	un	der Alaska Statute	. Political groups are parties who	 have applied for 	recognized political 	party 	
status but have not met the qualifications	. Alaska political affiliations are as follows:	 	
 
 
 
 	
 
       	Mail, fax or email (	as a 	PDF	, TIFF	 or 	JPEG 	attachment)	 your completed application to 	one of the 	offices	 listed	 below:	 	
Visit our website at: 	www.elections.alaska.gov	 	
Region I Elections Office	 	PO Box 110018	 	Juneau, AK 99811	-0018	 	(907) 465	-3021 	– Telephone	 	(907) 465	-2289 	– Fax	 	Toll Free 1	-866	-948	-8683	 	[email protected] 	 	 	
Region II Elections Office	 	Anchorage Office	 	2525 	Gambell Street Suite 100	 	Anchorage, AK 99503	-2838	 	(907) 522	-8683 	– Telephone	 	(907) 522	-2341 	– Fax	 	Toll Free 1	-866	-958	-8683	  	[email protected] 	 	Matanuska	-Susitna Office	 	North Fork Professional Building	 	1700 E. Bogard Road, Suite B102	 	Wasilla, AK 99654	-6565	 	(907) 373	-8952 	– Telephone	 	(907) 373	-8953 	– Fax	 	
Region III Elections Office	 	675 7	th Avenue Suite H3	 	Fairbanks, AK 99701	-4542	 	(907) 451	-2835 	– Telephone	 	(907) 451	-2832 	– Fax	 	Toll Free 1	-866	-959	-8683	  	[email protected] 	 	 	
Region IV Elections Office	 	PO Box 577	 	Nome, AK 99762	-0577	 	(907) 443	-5285 	– Telephone	 	(907) 443	-2973 	– Fax	 	Toll Free 1	-866	-953	-8683	 	[email protected] 	 	 Native Language Assistance	 	Toll Free 1	-866	-954	-8683	 	
Recognized Political Parties:	 	 Alaska Democratic Party	 	 Alaska Libertarian Party	 	 Alaska Republican Party	 	 Alaskan Independence Party	 	 	
Political Groups:	 	 Alaska Constitution Party	 	 Green Party of Alaska	 	 Twelve Visions Party of Alaska	 	 UCES’ Clowns Party	 	 Veteran’s Party of Alaska	 	
 	
Other:	 	 Nonpartisan (not affiliated with a political party or group)	 	 Undeclared (do not wish 	to declare a political affiliation)
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