New York State Voter Registration Form
Register to vote
With this form, you register to vote in elections in
New York State. You can also use this form to:
• change the name or address
on your voter registration
• become a member of a political party
• change your party membership
To register you must:
• be a US citizen;
• be 18 years old by the end of this year;
• not be in prison or on parole
for a felony conviction;
• not claim the right to vote elsewhere.
Información en español: si le interesa obtener este
formulario en español, llame al 1-800-367-8683
It is a crime to procure a false registration or to furnish false information to the Board of Elections.
Qualifications
Your name
More information
The address
where you live
The address where
you receive mail
Skip if same as above
Voting history
Voting information
that has changed
Skip if this has not changed
or you have not voted before
Identification
You must make 1 selection
For questions, please refer to
Verifying your identity above.
Political party
You must make 1 selection
To vote in a primary election,
you must be enrolled in one
of these listed parties —
except the Independence Party,
which permits non-enrolled
voters to participate in certain
primary elections.
Optional questions
DFD NYS Voter Reg Form 20100210_ENG.indd 1
Send or deliver this form
Fill out the form below and send it to your
Verifying your identity
We’ll try to check your identity before Election
county’s address on the back of this form, Day, through the DMV number (driver’s license
or take this form to the office of your County number or non-driver ID number), or the last
Board of Elections. four digits of your social security number,
which you’ll fill in below.
Mail or deliver this form at least 25 days before
the election you want to vote in. Your county will If you do not have a DMV or social security
notify you that you are registered to vote. number, you may use a valid photo ID, a current
utility bill, bank statement, paycheck, government
Questions? check or some other government document that
shows your name and address. You may include
Call your County Board of Elections a copy of one of those types of ID with this form—
listed on the back of this form or be sure to tape the sides of the form closed.
1-800-FOR-VOTE (TDD/TTY Dial 711)
If we are unable to verify your identity before
Find answers or tools on our website Election Day, you will be asked for ID when
www.elections.state.ny.us you vote for the first time.
中文資料:若您有興趣索取中文資料表格, 한국어: 한국어 양식을 원하시면
請電: 1-800-367-8683 1-800-367-8683 으로 전화 하십시오.
Please print in blue or black ink.
Are you a citizen of the U.S.? Yes No For board use only
1
If you answer No, you cannot register to vote.
Will you be 18 years of age or
2 older on or before election day? Yes No
If you answer No, you cannot register to vote unless you will be 18 by the end of the year.
Last name Suffix
3
First name Middle Initial
4 Birth date
M M / D D / Y Y Y Y 5 Sex M F
6 Telephone (optional)
– –
Address (not P.O. box)
Apt. Number Zip code
7
City/Town/Village
New York State County
Address or P.O. box
8 P.O. Box Zip code
City/Town/Village
9 Have you voted before? Yes No 10 What year?
Your name was
11 Your address was
Your previous state or New York State County was
New York State DMV number
12 x x x – x x –
Last four digits of your Social Security number
I do not have a New York State driver’s license or a Social Security number.
Democratic party Affidavit: I swear or affirm that
Republican party • I am a citizen of the United States.
• I will have lived in the county, city or village
Independence party for at least 30 days before the election.
13 Conservative party • I meet all requirements to register
to vote in New York State.
Working Families party • This is my signature or mark in the box below.
• The above information is true, I understand that
Other 15 if it is not true, I can be convicted and fined up
I do not wish to enroll in a party to $5,000 and/or jailed for up to four years.
I need to apply for Sign
an Absentee ballot (optional).
14
Rev. 01/2010
I would like to be an
Election Day worker (optional). Date
glue strip
3/17/10 2:57:43 PM
3/17/10 2:57:46 PM DFD NYS Voter Reg Form 20100210_ENG.indd 2
Address and stamp this section
Your address
Place
First-class
stamp
here
Your County Board of Elections address (select from below)
Before mailing
Remove tape,
fold and seal
New York City Chenango Franklin Lewis Oneida Putnam Schuyler Ulster
Executive Offices 5 Court St. 355 West Main St. 7660 N. State St. Union Station 1 Geneva Rd. County Office Bldg. 284 Wall St.
32 Broadway, 7th Fl. Norwich, NY 13815 Ste. 161 Lowville, NY 13367 321 Main St. Brewster, NY 10509 105 9th St., Unit 13 Kingston, NY 12401
New York, NY (607) 337-1760 Malone, NY 12953 (315) 376-5329 3rd Fl. (845) 278-6970 Watkins Glen, NY (845) 334-5470
10004 (518) 481-1663 Utica, NY 13501 14891
(212) 487-5300 Clinton Livingston (315) 798-5765 Rensselaer (607) 535-8195 Warren
Cnty Government Ctr. Fulton County Govt. Ctr. Ned Pattison Cnty. Municipal Ctr.
137 Margaret St. 2714 St. Hwy 29 6 Court St. Onondaga Government Ctr. Seneca 1340 St. Rte. 9
Albany Ste. 104 Ste. 1 Room 104 Civic Ctr. 1600 Seventh Ave. One DiPronio Dr. Lake George, NY
32 North Russell Road Plattsburgh, NY 12901 Johnstown, NY 12095 Geneseo, NY 14454 421 Montgomery St., Troy, NY 12180 Waterloo, NY 13165 12845
Albany, NY 12206 (518) 565-4740 (518) 736-5526 (585) 243-7090 15th Fl. (518) 270-2990 (315) 539-1760 (518) 761-6456
(518) 487-5060 Syracuse, NY 13202
Columbia Genesee Madison (315) 435-3312 Rockland Steuben Washington
Allegany 401 State St. County Building #1 County Office Bldg. 11 New Hempstead Rd. 3 E. Pulteney Sq. 383 Broadway
6 Schuyler St. Hudson, NY 12534 15 Main St. N. Court St. Ontario New City, NY 10956 Bath, NY 14810 Fort Edward, NY
Belmont, NY 14813 (518) 828-3115 PO Box 284 PO Box 666 74 Ontario St. (845) 638-5172 (607) 664-2260 12828
(585) 268-9294 Batavia, NY 14021 Wampsville, NY 13163 Canandaigua, NY (518) 746-2180
Cortland (585) 344-2550 (315) 366-2231 14424 St. Lawrence Suffolk
Broome County Office Bldg. 48 Court St. PO Box 700 Wayne
Government Plaza (585) 396-4005
60 Central Ave. Greene Monroe Canton, NY 13617 Yaphank Ave. 157 Montezuma St. Ext.
44 Hawley St. Room 102 411 Main St. 39 Main St. W. Orange (315) 379-2202 Yaphank, NY 11980 PO Box 636
PO Box 1766 Cortland, NY 13045 Ste. 437 Rochester, NY 14614 25 Court Lane (631) 852-4500 Lyons, NY 14489
Binghamton, NY (607) 753-5032 Catskill, NY 12414 (585) 753-1550 PO Box 30 Saratoga (315) 946-7400
13902 (518) 719-3550 Goshen, NY 10924 50 W. High St. Sullivan
(607) 778-2172 Delaware Montgomery (845) 291-2444 Ballston Spa, NY Gov’t. Ctr. Westchester
3 Gallant Ave. Hamilton Old Courthouse 12020 100 North St. 25 Quarropas St.
Cattaraugus Delhi, NY 13753 Rte. 8 9 Park St. Orleans (518) 885-2249 PO Box 5012 White Plains, NY
302 Court St. (607) 746-2315 PO Box 175 PO Box 1500 County Admin. Bldg. Monticello, NY 12701 10601
Little Valley, NY 14755 Lake Pleasant, NY Fonda, NY 12068 14016 State Rte. 31 Schenectady (845) 807-0400 (914) 995-5700
(716) 938-2400 Dutchess 12108 (518) 853-8180 Albion, NY 14411 388 Broadway, Ste. E
47 Cannon St. (518) 548-4684 (585) 589-3274 Schenectady, NY Tioga Wyoming
Cayuga Poughkeepsie, NY Nassau 12305 County Office Bldg. 4 Perry Ave.
10 Court St. 12601 Herkimer 240 Old Country Rd. Oswego (518) 377-2469 56 Main St. Warsaw, NY 14569
Auburn, NY 13021 (845) 486-2473 109 Mary St. 5th Fl. 185 E. Seneca St. Owego, NY 13827 (585) 786-8931
(315) 253-1285 Ste. 1306 Mineola, NY 11501 Box 9 Schoharie (607) 687-8261
Erie Herkimer, NY 13350 (516) 571-2411 Oswego, NY 13126 County Office Bldg. Yates
Chautauqua 134 W. Eagle St. 284 Main St. Tompkins Ste. 1124
7 North Erie St. (315) 867-1102 (315) 349-8350
Buffalo, NY 14202 Niagara PO Box 99 Court House Annex 417 Liberty St.
Mayville, NY 14757 (716) 858-8891 Jefferson 111 Main St. Otsego Schoharie, NY 12157 128 E. Buffalo St. Penn Yan, NY 14527
(716) 753-4580 175 Arsenal St. Ste. 100 Ste. 2 (518) 295-8388 Ithaca, NY 14850 (315) 536-5135
Essex Watertown, NY 13601 Lock port, NY 14094 140 County Hwy. 33W (607) 274-5522
Chemung 7551 Court St.
378 South Main St. (315) 785-3027 (716) 438-4040 Cooperstown, NY
PO Box 217 13326
PO Box 588 Elizabethtown, NY
Elmira, NY 14902 (607) 547-4247
12932
(607) 737-5475 (518) 873-3474
(Optional) Register to donate your organs and tissues
If you would like to be an organ and tissue donor, you may enroll in You will receive a confirmation letter from DOH, which will also
the NYS Department of Health (DOH) Donate Life™ Registry online provide you an opportunity to limit your donation.
at www.nyhealth.gov or provide your name and address below.
Last name By signing below,
you certify that you are:
First name
• 18 years of age or older;
Middle Initial Suffix • consenting to donate all of your organs and
tissues for transplantation, research, or both;
• authorizing the Board of Elections to provide
Address
your name and identifying information to
DOH for enrollment in the Registry;
Apt. Number Zip code • and authorizing DOH to allow access to this in-
formation to federally regulated organ procure-
City ment organizations and NYS-licensed tissue
and eye banks and hospitals upon your death.
Birth date
M M / D D / Y Y Y Y Sex M F
Eye color Height Ft. In.
Sign Date