Document Text
--- Document: VBM Voter Registration - English Document ---
EAL OF THE STATE OF NEW JER
New Jersey
Voter Registration Application
Please print clearly in ink. All information is required unless marked optional.
76
1 Check all boxes that apply:
New Registration
Address Change
Name Change
Signature Update
Political Party Affiliation
Vote By Mail
FOR OFFICIAL
USE ONLY
2 Are you a U.S. Citizen?
Yes No
3 Are you at least 17 years of age?
Yes No
(If No, DO NOT complete this form)
(If No, DO NOT complete this form)
4 Last Name
First Name
Middle Name or Initial Suffix (Jr., Sr., III)
Clerk
Registration #
5 Date of Birth (MM/DD/YYYY)
Office Time Stamp
6 Gender (Optional)
Female Male
7 NJ Driver's License Number or MVC Non-driver ID Number
If you DO NOT have a NJ Driver's License or MVC Non-Driver
ID, provide the last 4 digits of your Social Security Number.
"I swear or affirm that I DO NOT have a NJ Driver's License, MVC Non-driver ID or a Social Security Number."
8
Home Address (DO NOT use PO Box)
Apt.
Municipality (City/Town) County
State Zip Code
Mailing Address (if different from Home Address)
Apt.
Municipality (City/Town) County
State Zip Code
by mail
in person
9
Last Address Registered to Vote (DO NOT use PO Box) Apt. Municipality (City/Town) County
State Zip Code
Munt Code#
10
Former Name if Making Name Change
11
12 Day Phone Number (Optional)
E-Mail Address (Optional)
Party
Ward
District
13 Do you wish to declare a political party affiliation? Yes, the party name is
(Optional)
No, I do not wish to be affiliated with any political party.
14 Request for Mail-In Ballot for all future elections (Optional)
I wish to receive a Mail-In Ballot for all future elections until I request otherwise in writing to the County Clerk's office.
Mail my ballot to the following address if different from Mailing Address above.
Mailing Address if different from above
Apt.
Municipality (City/Town)
State Zip Code
Declaration - I swear or affirm that:
• I am a U.S. Citizen
• I live at the above home address
• I am at least 17 years old, and understand
that I may not vote until reaching the age of 18
• I will have resided in the State and county
at least 30 days before the next election
• I am not serving a sentence of incarceration
as the result of a conviction of any indictable
offense under the laws of this or another
state or of the United States.
I understand that any false or fraudulent
registration may subject me to a fine of up
to $15,000, imprisonment up to 5 years, or
both pursuant to R.S. 19:34-1
Signature of Registrant: Sign or mark and date on lines below
X
Date
(MM/DD/YYYY)
If applicant is unable to complete this form, print the
name and address of individual who completed this form.
Name
Address
Important Instructions for sections 7, 8, 13 and 14
7) Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not supply any of the information
required by section 7, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and valid
photo ID, or a document with your name and current address on it to avoid having to provide identification at the polling place.
Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers
illegally shall be subject to criminal penalties.
8) If you are homeless, you may complete section 8 by providing a contact point or the location where you spend most of your time.
13) You may declare a political party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a
previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than
55 days before the primary election in order to vote in the primary election. Completing section 13 is OPTIONAL and will not affect
the acceptance of your voter registration application.
14) If you wish to receive a Mail-In Ballot for all future elections, mark the appropriate box in section 14. You will continue to receive
Mail-In Ballots for all future elections until you request otherwise in writing to your County Clerk's office.
Need More Information? Check boxes below if you would like to receive more information about:
voting by mail
polling place accessibility
voting if you have a disability, including visual impairment
becoming a poll worker available election materials in this alternative language:
NJ Division of Elections-01/09/20
APPLICATION FOR VOTE BY MAIL BALLOT
Please type or print clearly in ink. All information required unless marked optional.
I hereby apply for a Mail-In Ballot for:
(CHECK ONLY ONE)
ALL FUTURE ELECTIONS, until I request otherwise in writing.
Or for ONLY ONE of the following: General (November)
Primary (June)
Municipal
School Fire
Special
To be held on
(Specify)
(MM/DD/YYYY)
MILITARY/OVERSEAS VOTER ONLY
I request Vote-By-Mail Ballots for all elections in which I am
eligible to vote and I am (CHECK ONLY ONE)
A Member of the Uniformed Services or Merchant Marine on
active duty, or an eligible spouse or dependent.
OAU.S. Citizen residing outside the U.S. and I intend to return.
AU.S. Citizen residing outside the U.S. and I do not intend to retum.
AU.S. Citizen residing outside the U.S. and I have never lived in the U.S.
PLEASE NOTE: Your ballot can only be sent to the mailing address supplied on this application.
If your mailing address changes, you must notify the County Clerk in writing.
Last Name (Type or Print)
First Name (Type or Print)
Middle Name or Initial
Suffix (Jr., Sr., III)
2
Address at which you are registered to vote:
Street Address or RD#
Apt.
Mail my ballot to the following address:
Same Address as Section 3
3
4
Municipality (City/Town)
State
Zip
Please include
any PO Box, RD#,
State/Province,
Zip/Postal Code
& Country
(if outside US)
Date of Birth (MM/DD/YYYY)
Day Time Phone Number
E-Mail Address
5
6
7
)
PLEASE NOTE: This contact information will be used to contact you concerning the acceptance or rejection of your ballot and how you may cure a defect.
Signature: I affirm that I am the person
8
who is applying for this ballot and I live at the
address designated in box 3 of this form.
X
Today's Date (MM/DD/YYYY)
9
OPTIONAL - ONLY COMPLETE SECTIONS 10 OR 11 IF APPLICABLE
Assistor: Any person providing assistance to the voter in completing this application must complete this section.
Name of Assistor (Type or Print)
10
Address
Signature of Assistor
X
Apt. Municipality (City/Town)
Date (MM/DD/YYYY)
1
State Zip
Authorized Messenger: Any voter may apply for a Mail-In Ballot by Authorized Messenger. Messenger shall be a family
member or a registered voter of this County. No Authorized Messenger can (1) be a Candidate in the election for which the voter is
requesting a Mail-In Ballot or (2) serve as messenger for more than THREE qualified voters per election, except that an authorized
messenger or bearer may serve as such for up to five qualified voters in an election if those voters are immediate family members
residing in the same household as the messenger or bearer.
I designate
Address of Messenger
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Signature of Voter
X
to be my Authorized Messenger.
Print Name of Authorized Messenger
Apt. Municipality (City/Town)
State
Zip
Date of Birth (MM/DD/YYYY)
Date (MM/DD/YYYY)
STOP Authorized Messenger must sign application and show photo ID
in the presence of the County Clerk or County Clerk designee.
"I do hereby certify that I will deliver the Mail-In Ballot directly to the voter
and no other person, under penalty of law."
Signature of Messenger
X
OFFICE USE ONLY
Voter Reg #
Date (MM/DD/YYYY)
Muni Code #
Party
Ward
District
NJ Division of Elections - 02/28/21
HUDSON COUNTY
★
★
NEW
JERSEY
APPLICATION
FOR
VOTE BY
MAIL BALLOT
VOTE
OFFICIAL
Postal Ser
Dear Registered Voter:
Attached is a Vote By Mail Application
for your use. If you would like to have
a ballot mailed to you, please complete
and return this application as soon as
possible.
After we receive your request, a ballot
will be mailed to you as soon as it is
available. If you have any questions or
concerns, please contact the Office of
the County Clerk, Division of Elections,
at (201) 369-3470, select option 6.
You can also access information at
the County Clerk website at www.
hudsoncountyclerk.org.
We look forward to serving you.
Sincerely,
E. Junior Maldonado
Clerk of Hudson County
VOTE BY MAIL BALLOT
APPLICATION FOR
POSTAGE WILL BE PAID BY ADDRESSEE
FIRST-CLASS MAIL PERMIT NO 555 JERSEY CITY, NJ
BUSINESS REPLY MAIL
JERSEY CITY, NJ 07302-9920
257 CORNELISON AVE 4TH FL
OFFICE OF THE HUDSON COUNTY CLERK
E. Junior Maldonado
Clerk of Hudson County
IN THE
IF MAILED
NECESSARY
NO POSTAGE
UNITED STATES