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Questions? Call your County Board of Elections or call 1-800-FOR-VOTE (Hearing Impaired?

1-800-533-8683 TDD)

YOUR ADDRESS: PUT


FIRST
CLASS
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HERE
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MAIL TO:

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To mail, put the address of your County Board of Elections in the “Mail To:” box
ALBANY DUTCHESS—47 Cannon St. LIVINGSTON—County Gov’t. Center OSWEGO—46 E. Bridge St. SUFFOLK—PO Box 700,
32 North Russell Road Poughkeepsie, NY 12601 6 Court Street, Room 104 Oswego, NY 13126 Yaphank Ave.
Albany, NY 12206 (845) 486-2473 Geneseo, NY 14454-1043 (315) 349-8350 Yaphank, NY 11980
(518) 487-5060 (585) 243-7090 (631) 852-4500
ERIE—134 W. Eagle St. OTSEGO—Suite 2
ALLEGANY—6 Schuyler Street Buffalo, NY 14202 MADISON—County Office Bldg. 140 County Hwy. 33W SULLIVAN—Gov’t. Center
Belmont, NY 14813-1085 (716) 858-8891 PO Box 666 Cooperstown, NY 13326 100 North St., PO Box 5012
(585) 268-9294 Wampsville, NY 13163 (607) 547-4247 Monticello, NY 12701-5192
ESSEX—7551 Court St. (315) 366-2231 (845) 794-3000 ext. 5024
BROOME—Government Plaza P.O. Box 217 PUTNAM—1 Geneva Rd.
44 Hawley Street, P.O. Box 1766 Elizabethtown, NY 12932 MONROE—39 Main St. W. Brewster, NY 10509 TIOGA—County Office Bldg.
Binghamton, NY 13902 (518) 873-3474 Rochester, NY 14614 (845) 278-6970 56 Main St.
(607) 778-2172 (585) 428-4550 Owego, NY 13827
FRANKLIN—355 West Main St. RENSSELAER—Ned Pattison (607) 687-8261
CATTARAUGUS—302 Court St. Suite 155 MONTGOMERY—Old Courthouse Gov’t Cntr.
Little Valley, NY 14755 Malone, NY 12953 9 Park Street 1600 Seventh Avenue TOMPKINS—Court House Annex
(716) 938-9111 (518) 481-1663 Fonda, NY 12068-1500 Troy, NY 12180 128 E. Buffalo St. Ithaca, NY 14850
(518) 853-8182 (518) 270-2990 (607) 274-5522
CAYUGA—10 Court Street FULTON—2714 St. Hwy 29, Ste. 1
Auburn, NY 13021 Johnstown, NY 12095 NASSAU—400 County Seat Drive ROCKLAND—11 New Hempstead Rd. ULSTER—284 Wall St.
(315) 253-1285 (518) 736-5526 Mineola, NY 11501 New City, NY 10956 Kingston, NY 12401
(516) 571-2411 (845) 638-5172 (845) 334-5470
CHAUTAUQUA—3 North Erie St. GENESEE—County Building #1
Mayville, NY 14757 15 Main St., PO Box 284 NEW YORK CITY - Executive Offices ST. LAWRENCE—48 Court St. WARREN—Warren County
(716) 753-4580 Batavia, NY 14021 32 Broadway, 7th Floor Canton, NY 13617 Municipal Center
(585) 344-2550 New York, NY 10004 (315) 379-2202 1340 St. Rte. 9
CHEMUNG—378 South Main St. (212) 487-5300 Lake George, NY 12845
PO Box 588, Elmira, NY 14902-0588 GREENE—411 Main St., 4th Floor SARATOGA—50 W. High St. (518) 761-6456
(607) 737-5475 PO Box 307 NIAGARA—111 Main St., Suite 100 Ballston Spa, NY 12020
Catskill, NY 12414 Lockport, NY 14094 (518) 885-2249 WASHINGTON—383 Broadway
CHENANGO—5 Court St. (716) 438-4040 Fort Edward, NY 12828
Norwich, NY 13815 (518) 719-3550 SCHENECTADY—388 Broadway (518) 746-2180
(607) 337-1760 HAMILTON—Route 8 ONEIDA—Union Station Suite E,
PO Box 175 321 Main St., 3rd Floor Schenectady, NY 12305-2520 WAYNE—157 Montezuma St. Ext.
CLINTON—County Government Center Utica, NY 13501 PO Box 636,
137 Margaret St., Suite 104 Lake Pleasant, NY 12108 (518) 377-2469
(518) 548-4684 (315) 798-5765 Lyons, NY 14489-0636
Plattsburgh, NY 12901 SCHOHARIE—County Office Bldg. (315) 946-7400
(518) 565-4740 HERKIMER—109 Mary St. ONONDAGA—Civic Center 284 Main St., PO Box 99
Suite 1306, Herkimer, NY 13350 421 Montgomery St., 15th Floor Schoharie, NY 12157 WESTCHESTER—25 Quarropas St.
COLUMBIA—401 State Street Syracuse, NY 13202 White Plains, NY 10601
Hudson, NY 12534 (315) 867-1102 (518) 295-8388
(315) 435-3312 (914) 995-5700
(518) 828-3115 JEFFERSON—175 Arsenal St. SCHUYLER—County Office Bldg.
Watertown, NY 13601 ONTARIO—20 Ontario St. 105 9th St., Unit 13 WYOMING—76 North Main St.
CORTLAND—County Office Bldg. Canandaigua, NY 14424 Warsaw, NY 14569
60 Central Ave., Room 102 (315) 785-3027 Watkins Glen, NY 14891-1435
(585) 396-4005 (607) 535-8195 (585) 786-8931
Cortland, NY 13045-2746 LEWIS—Court House
(607) 753-5032 7660 N. State St. ORANGE—25 Court Lane SENECA—One Di Pronio Dr. YATES—Suite 1124
Lowville, NY 13367 PO Box 30, Goshen, NY 10924 Waterloo, NY 13165 417 Liberty St.
DELAWARE—3 Gallant Ave. (845) 291-2444 Penn Yan, NY 14527
Delhi, NY 13753 (315) 376-5329 (315) 539-1760
(315) 536-5135
(607) 746-2315 ORLEANS—County Admin. Bldg. STEUBEN—3 E. Pulteney Sq.
14016 State Rte. 31 Bath, NY 14810
Albion, NY 14411 (607) 664-2260
(585) 589-3274 .
New York State Voter Registration Form
You Can Use This Form To: In Order To Vote: Questions? Call your county board of
• register to vote in New York State • you can register in person at your elections. Find the phone number on the other
• change your name and/or address, if there is county board of elections side of this form.
a change since you last voted • to vote in an election, you must Hearing impaired people with TDD/TTY may
• enroll in a political party or change your mail or deliver this form to your call the New York State Relay #711.
enrollment county board no later than 25 days Visit our website - www.elections.state.ny.us
To Register You Must: before the election in which you
• be a U.S. citizen Información en español: si le interesa obtener
want to vote
• be 18 years old by the end of this year este formulario en español, llame al
• be 18 years old by the date of the 1-800-367-8683
• not be in jail or on parole for a felony conviction election in which you want to vote
• not claim the right to vote elsewhere • your eligibility to vote will be
Need More Registration Forms? based on the date you file this form
You can get registration forms at most state • your county board will notify you
agency offices and post offices or at any county of your eligibility
board of elections or call 1-800-FOR-VOTE.

IDENTIFICATION REQUIREMENTS TO COMPLETE THIS FORM:


Your identity must be verified prior to election day, so that you will Box 9: If you have a current DMV number, you must provide that
not have to provide identification when you vote. Your identity can number. If you do not have a current DMV number, you must
be verified through your DMV number (driver’s license number or provide the last four digits of your social security number.
non-driver ID number), or the last four digits of your social security
Box 10: If you have never voted before, write “None.” If you can’t
number, as requested in Box 9 of this application.
remember when you last voted, put a question mark (?). If you
If your identity is not verified before election day, you will be asked voted before under a different name, put down that name. If not,
to provide identification when you vote for the first time. Samples of write “Same.”
the identification you may provide include a valid photo ID, a current
utility bill, bank statement, government check or some other govern- Box 11: Check one box only. In order to vote in a party primary,
ment document that shows your name and address. you must be enrolled in one of New York’s 5 constituted parties.
If you include a copy of any identification with this application, be *Except the Independence Party, which permits non-enrolled
sure to tape the sides of this form closed. voters to vote in their primary elections.
If you would like an application for an ABSENTEE BALLOT or would like to be an ELECTION DAY WORKER,
please check the corresponding box below.

Yes, I need an application for an Absentee Ballot Please print in blue or black ink Yes, I would like to be an Election Day Worker
Are you a U.S. citizen? I will be 18 years old on or before election day:
For Board use only!
Yes No
1 Yes No 2 If you answered NO, do not complete this form,
If you answered NO, do not complete this form. unless you will be 18 by the end of the year.
Last Name First Name Middle Initial Suffix
3
Home Address Where You Live (do not give P.O. address) Apt. No. City/Town/Village Zip Code County
4
Address Where You Get Your Mail (if different from home address) P.O. box, star rte., etc. Post Office Zip Code
5
Date of Birth Sex (circle) Home Tel. Number (optional) ID Number - Check the applicable box and provide your number
6 7 M F 8 New York DMV number
The last year you voted Your Address was (give house number, street, and city)
If you do not have a New York DMV number, please provide
9
Last four (4) digits of your
10 In county/state Under the name (if different from your name now)
Social Security number
I do not have a New York DMV number or a Social Security
number.
Choose a Party — Check one box only AFFIDAVIT: I swear or affirm that
DEMOCRATIC PARTY • I am a citizen of the United States.

}
To vote in a
primary • I will have lived in the county, city, or village for at least 30 days before the election.
REPUBLICAN PARTY • I meet all requirements to register to vote in New York State.
election, you
INDEPENDENCE PARTY must be enrolled • This is my signature or mark on the line below.
in one of these • The above information is true. I understand that if it is not true I can be convicted and
11 CONSERVATIVE PARTY parties.
12 fined up to $5,000 and/or jailed for up to four years.
* See above

WORKING FAMILIES PARTY Signature or mark in ink

OTHER (write in)


I DO NOT WISH TO ENROLL IN A PARTY x Date

Please do not write in this space