West Virginia Voter Registration Form

West Virginia Voter Registration Form.pdf Download and Submit the form to the state office to register for voting in the state of West Virginia

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West Virginia Voter Registra on Applica on

Please follow these steps to complete this form. (Please PRINT in blue or black ink.) REGISTRATION DEADLINE: You may submit a
registra on applica on at any me. However,
Box 1: Indicate if this is a new registra on, party Box 8: Enter the address where you were last in order to vote in an elec on, you must register
change, or name/address change. registered to vote and the name under
twenty-one (21) days before that elec on.
which you were registered.
Box 2.* Provide your full legal name, including Box 9: Provide a telephone number. For county clerk contact informa on, including
any suffix (Jr., Sr., III, etc.). mailing addresses, please visit www.wvsos.com.
Box 10: Select your party choice. If you do not
Box 3.* Provide your date of birth (MM/DD/YYYY). make a selec on, you will be registered If you are registering to vote for the fi rst me
You must be at least seventeen years old to as “unaffiliated.” Some poli cal in West Virginia, or for the fi rst me in this
apply to register to vote and will be eighteen par es may allow voters not affiliated county and you have not cast a vote in a federal
on or before the next general elec on. with their party to cast a ballot in their elec on in this state, you must submit a copy

party’s primary elec ons.
Box 4.* Enter your WV driver’s license or DMV-issued of a current and valid ID with this applica on
non-driver’s ID number. If you do not have a WV Box 11: Check if you would like to be or the fi rst me you vote. To submit with this
driver’s license or DMV-issued ID, enter the last contacted about serving as a poll form, include: 1) a copy of a current and valid
four digits of your social security number. If you worker.
photo ID, or 2) a copy of a current u lity bill,
do not have a driver’s license, DMV ID or a social
security number, enter the word “NONE”. An Box 12:* Carefully read the statement. If the bank statement, government check, paycheck
ID number will be assigned to you. statement is true, sign and date where or other government document that shows
indicated. Knowingly providing false
your name and current residence address.
Box 5.* Line 1 Provide your legal residence information is perjury, punishable
address (do not enter a P.O. Box.)** on conviction by confinement in a *Required informa on. Your registra on
Include the name of the county where peniten ary for not less than one nor
more than ten years. cannot be processed without this
you reside.
informa on.
Line 2 Provide your mailing address,
if diff erent from your legal residence QUESTIONS? **Overseas ci zens who no longer reside in the U.S.
address. Contact your local county clerk or
go to www.wvsos.com may enter the last address at which they legally
Box 6: Provide an email address. Call toll-free resided. Uniformed service voters should check
1-866-767-8683 with the Federal Vo ng Assistance Program for
Box 7: Indicate your gender. West Virginia Secretary of State current instruc ons: www.fvap.gov.

FOR OFFICIAL USE

PRECINCT:
Are you a ci zen of the United States of America? YES NO If you answered “no” to either
Will you be 18 years of age on or before the next YES NO of these questions, do not
general elec on? complete this form. VOTER ID:

1 NEW REGISTRATION PARTY CHANGE NAME/ADDRESS CHANGE 3* DATE OF BIRTH
/ /
2* LAST NAME FIRST NAME MIDDLE NAME SUFFIX (Circle)
DRIVER’S LICENSE # or
Jr. Sr. II 4* ID
DMV ISSUED ID #:
III IV V CONFIRMATION:

LEGAL RESIDENCE (HOUSE NUMBER/STREET NAME, CITY/ZIP) COUNTY
5* If neither, enter the last four
digits of your Social Security #:
XXX-XX- DATE
MAILING ADDRESS (IF DIFFERENT FROM LEGAL RESIDENCE ADDRESS) 6 EMAIL RECEIVED:

8 YOUR NAME AND ADDRESS WHERE YOU LAST REGISTERED TO VOTE 7 GENDER M F

9 TELEPHONE (Office Use)

10 PARTY: DEMOCRATIC REPUBLICAN MOUNTAIN UNAFFILIATED OTHER 11 I WOULD LIKE TO BE A POLL WORKER
12 *
I swear or affirm that: DATE:

• 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 PRECINCT:

• I have not been judged incompetent by a court of competent
R-2 jurisdic on.
SIGNATURE
08/11

ITEMS MARKED WITH AN “*” ARE REQUIRED FOR PROCESSING THIS APPLICATION.

 

LAST NAME FIRST NAME MIDDLE INIT. PCT.
MUNICIPAL
RECORD OF PARTY AFFILIATION
SPECIAL ELECTION
MUNICIPAL DATE PARTY CLERK
PRIMARY ELECTION
MUNICIPAL
GENERAL ELECTION
STATE-COUNTY
SPECIAL ELECTION
STATE-COUNTY
PRIMARY ELECTION
STATE-COUNTY RECORD OF NOTICES
GENERAL ELECTION
(Record fact of vo ng with a check ( ) mark in the proper space. At DATE TYPE RESPONSE CLERK
primaries record fact of vo ng by use of party ini al or ini als.)

RECORD OF RESIDENCE