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West Virginia Voter Registration Form

In order to register for voting in the State of West Virginia, you are required to fill and submit the form the state office.

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West Virginia Voter Registra on Applica on
Box 1:
Box 2.*Indicate if this is a new registra on, party 
change, or name/address change.
Box 7:	
REGISTRATION DEADLINE:  You may submit a 
registra on applica on at any  me.  However, 
in order to vote in an elec  on, you must register 
twenty-one (21) days before that elec on.	
1	
PRECINCT:
VOTER ID:
ID
CONFIRMATION:
DATE
RECEIVED:
PRECINCT:	NOIf you answered “no” to either 
of these questions, do not 
complete this form.	
NAME/ADDRESS CHANGE PARTY CHANGE NEW REGISTRATION	
LAST NAME FIRST NAME MIDDLE NAME	2*	
III
IVVJr.
Sr.
II	
3*
4*	
5*	
6	
8	7	
DRIVER’S LICENSE # or 
DMV ISSUED ID #:	
XXX-XX-	
LEGAL RESIDENCE (HOUSE NUMBER/STREET NAME, CITY/ZIP)
MAILING ADDRESS (IF DIFFERENT FROM LEGAL RESIDENCE ADDRESS)
EMAIL	
9	
12 *
10	
YES
YES
NO	
Please follow these steps to complete this form.	  	
Provide your full legal name, including 
any suffi    x (Jr., Sr., III, etc.).
Box 3.*
Provide your date of birth (MM/DD/YYYY). 
You must be at least seventeen years old to 
apply to register to vote and will be eighteen 
on or before the next general elec on.
Box 4.*
Box 5.*Enter your WV driver’s license or DMV-issued 
non-driver’s ID number. If you do not have a WV  
driver’s license or DMV-issued ID, enter the last 
four digits of your social security number.  If you 
do not have a driver’s license, DMV ID or a social  
security number, enter the word “NONE”.  An 
ID number will be assigned to you.Box 8:
Box 9:
Box 10:
Check if you would like to be 
contacted about serving as  a poll 
worker.
Box 12:*Carefully read the statement.  If the 
statement is true, sign and date where 
indicated.  Knowingly providing false 
information is perjury, punishable 
on conviction by confinement in a 
peniten  ary for not less than one nor 
more than ten years.	
*Required informaŸ  on. Your registraŸ on 
cannot be processed without this 
informaŸ on.
**Overseas ciŸ  zens who no longer reside in the U.S. 
may enter the last address at which they legally 
resided.  Uniformed service voters should check  
with the Federal VoŸ ng Assistance Program for 
current instrucŸ ons: www.fvap.gov.	
Box 6:	
Enter the address where you were last 
registered to vote and the name under 
which you were registered.	
If neither, enter the last four 
digits of your Social Security #:	
Box 11:	
QUESTIONS?	Contact your local county clerk or
go to www.wvsos.com
Call toll-free
1-866-767-8683
West Virginia Secretary of State	
FOR OFFICIAL USE	
11	
Are you a ci  zen of the United States of America?
Will you be 18 years of age on or before the next 
general elec on?	
(Please PRINT in blue or black ink.)	
Line 1  Provide your legal residence 
address (do not enter a P.O. Box.)** 
Include the name of the county where 
you reside.
Line 2  Provide your mailing address, 
if diff erent from your legal residence 
address.
Provide an email address.
Indicate your gender.Provide a telephone number.
Select your party choice.  If you do not 
make a selec  on, you will be registered 
as “unaffi  liated.”  Some poli cal 
par es may allow voters not affi  liated 
with their party to cast a ballot in their 
party’s primary elec ons.	
For county clerk contact informa on, including 
mailing addresses, please visit www.wvsos.com.
If you are registering to vote for the fi rst  me 
in West Virginia, or for the fi rst  me in this 
county and you have not cast a vote in a federal 
elec  on in this state, you must submit a copy 
of a current and valid ID with this applica on 
or the fi rst   me you vote.  To submit with this 
form, include: 1) a copy of a current and valid 
photo ID, or 2) a copy of a current u lity bill, 
bank statement, government check, paycheck 
or other government document that shows 
your name and current residence address.	
SUFFIX (Circle)
COUNTY
YOUR NAME AND ADDRESS WHERE YOU LAST REGISTERED TO VOTEDATE OF BIRTH	
GENDER
TELEPHONE (Offi  ce Use)
I WOULD LIKE TO BE A POLL WORKER	
•  I am a ci  zen of the United States;
•  I am at least 17 years of age and will be 18 on or before the 
next general elec on;
•  My legal West Virginia residence address is listed in Box 5;
•  I am not under convic on, proba  on or parole for elec on 
bribery, treason, or any felony; and
•  I have not been judged incompetent by a court of competent  
jurisdic on.	
DATE:	
PA R T Y:	 DEMOCRATIC
REPUBLICAN
MOUNTAINUNAFFILIATEDOTHER	
SIGNATURE	
M
F	
I swear or affi  rm that:	
/           /	
ITEMS MARKED WITH AN “    ” ARE REQUIRED FOR PROCESSING THIS APPLICATION.	*	
R-2
08/11

RECORD OF RESIDENCE	
PCT. CITY ADDRESS
APT. OR
ROOM NO.DATE CLERK
MUNICIPAL
SPECIAL ELECTION
MUNICIPAL
PRIMARY ELECTION
MUNICIPAL
GENERAL ELECTION
STATE-COUNTY
SPECIAL ELECTION
STATE-COUNTY
PRIMARY ELECTION
STATE-COUNTY
GENERAL ELECTION2
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OFFICE USE ONLY (Please remember to enter all information in the voter registration system)	
RECORD OF NOTICES
RECORD OF PARTY AFFILIATION	DATE PARTY CLERK
LAST NAME FIRST NAME MIDDLE INIT. PCT.
DATE TYPE RESPONSE CLERK
(Record fact of vo  ng with a check (	) mark in the proper space.  At
primaries record fact of vo  ng by use of party ini  al or ini als.)	
Return Address	
OFFICIAL ELECTION MATERIALCLERK OF THE COUNTY COMMISSION
County Courthouse
WV	
City Zip	
POST OFFICE WILL NOT 
DELIVER WITHOUT 
POSTAGE	
PLACE
STAMP
HERE
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