Vermont Application for Addition to the Checklist (VT Voter Registration Form)

Subject registering for voting by filing the Vermont Application for Addition to the Checklist (VT Voter Registration Form) will be assessed by the Town Clerk or the Board of Civil Authority regarding the eligibility requirements.

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VERMONT Application for Addition to the Checklist (VT VOTER REGISTRATION FORM	) 
17 V.S.A. § 2145  (Please print clearly, use ballpoi nt pen, and bear down hard.) 	
I, ________________________________________________ ______________ 	apply to have my name 	
(Last Name)      (First Name)      (Middle Initial	) 	 
added to the checklist of the Town/City of ______________________________________.  
By checking the boxes below, I swear or affirm that  these are true statements: 
   Yes     No  Are you a citizen of the United States?   
   Yes     No  Will you be eighteen years of age or older on o r before the day of election? 
   Yes     No  Are you a resident of Vermont? 
If you checked "No" in response to any of the three  questions above, DO NOT complete this form. You are not qualified 
to vote in Vermont	
.  Contact the Office of the Secretary of State, El ections Division, for more information at (800) 439 -8683. 	
I was born on ________________________ at _________ ________________________,  ________________________ ___ 
   	
(Date)        (Town or City)               (State) 	 
My principal dwelling is located at:_______________ ___________________________________________________ ____  
         	
(E911 street address including number or exact phys ical location, if no E911 address) 	
Mailing Address: ___________________________________________________ ________ Tel. #: ___________________   
Email:__________________________________________ 	(optional - for contact purposes only).	   	 	
 	 	
By registering to vote in the above named town in V ermont, I authorize my name to be removed from the  list of registered voters in any 
previous place where I was registered to vote.  	 	
The last address I was registered to vote at: ___________________________________________________ _______. 
         	   	(Physical location – include number, street, town,  state and zip code) 	
I was previously registered with a different last name of: ___________________________ ____________________________. 
 
My VT Driver’s License or Personal I.D. #  (PID#) issued by VT DMV is__________________.   	This # is REQUIRED. 	
IF you do not have a VT Driver’s License or PID# issued by VT DMV enter the last 4 digits of your Social Security 
Number:________ .  If you do not have a VT PID#, or SSN, please contac t the Office of the Secretary of State, Elections Division, 
(800)439-8683. 
By checking this box I swear or affirm that:  
  I have taken the Voter's Oath  
 
I meet all of the eligibility requirements to vote  in this municipality	.  I hereby swear, or affirm, under penalty of perjury 
and other potential federal or state criminal penal ties of up to a $10,000 fine, or imprisonment for not more than fifteen years, or 
both, that the statements made by me in this applic ation are true	
. (17 V.S.A. § 2145(f); 17 V.S.A. § 2011;  42 U.S.C. § 1973gg-10). 	
____________________________        ___________________ ___________________________ 
   Today’s Date                  Applicant’s Signature  
First time Registrants in Vermont must take the voter’s oath. 	You must be 18 to take the oath:  	
VOTER'S OATH (Vermont Constitution, Chapter II, Section 42):	 “You solemnly swear or affirm that whenever you gi ve your vote or 
suffrage, touching any matter that concerns the Sta te of Vermont, you will do it so as in your conscience you shall judge will 
most conduce to the best good of the same, as estab lished by the Constitution, without fear or favor of any person.” 
The person administering the oath	
 or the applicant must sign the certification below.  
I hereby certify that on the___ day of ____________ ____, 20___,  I administered the Voter’s Oath to the applicant,  or  	
 I, the applicant, took the oath myself. Any person  over 18 or the applicant can sign to attest that the oath was taken. 
  (Check box above & sign.)  Attestation:____________ __________________________     
               	Signature of Attester 	 
ONLY 	if you are registering to vote for the 1	st time in Vermont, AND	 you are mailing this application to your town clerk  	
individually, you must submit a photocopy of one of the followi ng:  current & valid photo identification OR bank statement, utility bill, or 
government document with your name and current addr ess.  (Do not submit I.D. if you have been previously reg istered in VT, if this 
form is submitted as part of a voter registration drive, or if you return this form to the clerk’s office in person.) 
 
FOR OFFICIAL USE :  
 The Town Clerk OR  
the BCA has reviewed the application AND the applic ant 
 was added to the checklist. 
The applicant’s usual polling place is: ___________ __________________________________. OR the applican t 
  was rejected and 
NOT added to the checklist.  The reason(s) for reje ction are:    _____________________________________ .  
Signature of town clerk: ____________________________. 
Date Entered on Checklist: _____________  Date Noti fication Sent  to Voter:_____________  Date Approved: ____________ 
 
KEEP THE PINK COPY OF THIS APPLICATION FORM	.  Contact your Town Clerk to make sure your application has been received.  
Bring pink copy to the polls when you go to vote .  This is proof you have submitted an application before the deadline for registration. 
                         	
[SOS-VR-5/12/2014]

VERMONT VOTER REGISTRATION INFORMATION 
(HOW TO FILL OUT THE Vermont APPLICATION FOR ADDITI ON TO THE CHECKLIST) 
To be eligible to vote in Vermont you must:     (Eligibility requirements are in 17 V.S.A. § 2121, 2122) 
1.  be a citizen of the United States;  
2.  be a resident of Vermont and a resident of the  town in which you apply to be added to the checklis t; (OR be a military 
or overseas voter qualified under the federal Unifo rmed and Overseas Citizens Absentee Voting Act whos e last place of 
residence in the United States immediately prior to  moving overseas was in a Vermont town or city); 
3.  take, or have previously taken, the Voter's Oat h; and 
4.  be 18 years of age or older or will be 18 on or  before the day of election. 
 	
THE APPLICANT MUST REGISTER TO VOTE IN THE TOWN OR  CITY WHERE HE or SHE CURRENTLY RESIDES. 
If you are registering to vote for the 1	st time in Vermont, and you are mailing this application to your town clerk 	
individually, you must also submit a photocopy of o ne of the following forms of identification: current & valid 
photo identification or bank statement, utility bill, or government document that contains your name/c urrent 
address.  NO photocopy of ID is required when a person registers through a state agency. 
 
You must include your Vermont DMV-issued Driver’s License Number or Personal I.D. Number (VT PID#) on the voter 
application .  If you do not have a Driver’s License or VT PID#  issued by DMV, then you must include the last four  (4) digits of 
your Social Security Number. (SSN).   If you do not have either, please contact the Off ice of the Secretary of State. 
  
Providing your e-mail address is optional, but prov ides the easiest way for the Clerk to contact you. 
 
Where to File: Keep the pink copy, and submit the top two sheets (the white and cana ry copies) of the form to the Town or City 
Clerk  in  the  town  or  city  in  which  you  reside.  Cler k  addresses  can  be  found  on  the  Secretary  of  State’s  web  site, 
http://	
www.sec.state.vt.us	, or call your town clerk, or call the Elections Di vision at (802) 828-2363 or (800) 439-8683.  YOU 
MUST REGISTER TO VOTE IN THE TOWN OR CITY WHERE YOU  CURRENTLY RESIDE. 
  
When to File:  The application must be received by 5:00 PM on the  Wednesday immediately prior to the day of an election in order 
to vote in that election .  If you apply through a state agency, your applica tion must be postmarked or accepted on or before th e 
Wednesday preceding the election.   
Getting on the Voter Checklist :  You are not automatically registered to vote by  filing this application.  If the Town Clerk or the 
Board of Civil Authority finds that you meet the el igibility requirements you will be added to the checklist and become a registered 
voter.  You will be notified in writing whether or  not your application has been approved.  If you hav e not received notification, call 
your town clerk.  If you are not eligible, the Boar d must state the reason in writing and give you a c hance to be reconsidered.  If you 
are still denied, you can appeal in writing to a su perior or district judge in your county. (No filing  fee or lawyer is required.) 
  
Voter’s Oath : If you have previously voted in Vermont, do not tak e the voter’s oath again.  If not, the oath can be 	
administered by yourself	, by any person over the age of 18, by the Town Cle rk, a Justice of the Peace, a Notary Public, or a 
Commissioned Military Officer.  If you do not take  oaths you may take it as an affirmation.  The person who administered the 
oath, or you if you are attesting for yourself that  you have taken the oath, must date and sign the at testation in the box.  	
 
SERIOUS PENALTIES FOR FALSE INFORMATION ON AN APPLI CATION TO THE CHECKLIST	 
It is unlawful to give false information concerning  your qualifications to be a registered voter of a town or city in 
Vermont.  The penalties are serious, including pena lties of up to a $10,000 fine or imprisonment for not more than 
fifteen years, or both. 	
 
Note to Town and City Clerks:  	The applicant retains the pink copy when the applic ation is completed.  After the Town 	
Clerk or BCA takes action, complete the bottom of t he application form and mail a copy to the applicant. 
 
The laws relating to voter registration are in 17 V. S. A. §§2121-2150.  If you have questions, call y our town clerk or 
call the Elections Division, Office of the Secretar y of State at (802) 828-2363, or (in Vermont) (800)  439-8683. 
  
Note:  If you were provided this form when you applied for  assistance or services from a state agency you may decline to register.  If you decline to register 
your failure to register will remain confidential a nd will be used only for voter registration purpose s.  The fact that you may have submitted this application in 
connection with a motor vehicle driver’s license ap plication or renewal, or through a voter registration agency will remain confidential and will be used  only 
for voter registration purposes.