REGISTER AND VOTE

www.VotesPA.com

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To Register You Must:

PENNSYLVANIA VOTER REGISTRATION MAIL APPLICATION

Be a citizen of the United States for at least one month before the next election; Be a resident of Pennsylvania and your election district for at least 30 days before the next election; and Be at least 18 years of age on the day of the next election.

GENERAL INSTRUCTIONS 1. Please provide all information on the application as required. Read all instructions carefully before you fill out the application. 2. If you are currently registered, you do not need to re-register unless you have moved or changed your name since you last registered. 3. In order to vote in the next election, this application must be received by your county voter registration office no later than 30 days before the election, or postmarked no later than the thirtieth day before the election. Military electors may apply at any time. For more information on military and overseas electors, see www.fvap.gov. 4. Write the mailing address for your county voter registration office on the reverse side of this application and place the proper postage in the designated area. Addresses for all Pennsylvania counties are listed on the back of this form. 5. You are not registered to vote until your application has been processed and accepted by the county voter registration office. If accepted, the county voter registration office will send you, via nonforwardable mail, a Voter Identification Card. If you do not receive a Voter Identification Card within 14 days of the date you submit this application, contact your county voter registration office. 6. If you decline to register to vote, your decision will remain confidential. If you register to vote, the office at which you register will remain confidential and be used for voter registration purposes only. 7. Do not use staples or duct tape. 8. Print and sign clearly in blue or black pen.

3b Pennyslvania Driver’s License OR Social Security Number: You must supply a PA Driver’s License Number if you have one. If you do not have a PA Driver’s License Number, you must supply the last four digits of your Social Security Number. If you do not have a Social Security Number, please check the box to the right of 3b. 4a Address of Residence: Fill in your complete address of residence. P.O. boxes may not be used here unless there is no physical address. Print street address, city and zip code. (If the residence is only a portion of the house, include the location of the room, apartment or floor which is occupied.) 4b Although providing your telephone number is optional, it is a quick and easy way for your county to contact you if there is missing information on your registration form. In Box 4c fill in the name of the municipality (city, borough or township) and county where you live. Use the map in the box below if you cannot otherwise identify your address.

Prior Registration: If you were registered before, fill in the name used on your previous registration in Box 8a and address, county and year of previous registration in Box 8b. Name of Assistant: If the applicant is unable to complete or sign the application, the person who assisted the applicant must provide his or her name, address and signature. Registration Declaration: You must be a citizen of the United States to register to vote in the Commonwealth of Pennsylvania. Please read the registration declaration carefully. You must sign and print your name and date the application. If you were assigned a Voter Identification Number, which appears on your Voter Identification Card, place that Identification Number, if available here. If you are applying to register to vote for the first time, leave this box blank. If you require assistance when voting, you must check the box and provide the reason.

PENALTY FOR FALSIFYING REGISTRATION DECLARATION WARNING: If a person signs an official registration application knowing a statement declared in the application to be false, makes a false registration, or furnishes false information, the person commits perjury. Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven years, or a fine not exceeding $15,000, or both, at the discretion of the court. Submitting an application containing false information may also subject a person to other penalties, including loss of the right of suffrage, under state or federal law.

PENNSYLVANIA VOTER REGISTRATION APPLICATION

1 2 3
a

Are you a citizen of the United States of America? Will you be 18 years of age on or before election day?
New Registration
M Last Name F

Yes Yes

No No

}

If you checked “No” in response to either of these questions, do not complete this form.
I am a Federal or State employee and wish to retain my voting residence in the county where I last resided.
Middle Name/Initial

Change of Name

Change of Address
First Name

Change of Party

Jr Sr II III IV
(circle if applicable)

Driver’s 3 Place PA(DL) # here License

4 4
c a

b

if you have one:

If no PA DL #, Place SS# (last 4 digits) here:
Apt # State Zip Code

I DO NOT have a PA Driver’s License or Social Security Number.

Address of residence, include street and city (Use map above if no street number or name) (If only P.O. box, see above)

Municipality where you live

County where you live

5

PA

4
b

Telephone Number (Optional)

(

)

Mailing Address (if different than address of residence)

City

State Zip Code

Address of previous registration (include street and city) 6 Date of Birth 7 Race (Optional) 8 Name on previous registration a / / 8 wish to register? You must with a party 9 In which party do youRepublican LibertarianregisterNo affiliationif you want to take part in that party’s primary. b County of previous registration Year of previous registration Democratic Other

10 Address

Name and signature of person who assisted in the completion of this application

Place signatue with full name (or mark) below (Please see Penalty for Falsifying Declaration.)

HEREBY DECLARE THAT: 11 I(1) On the day of the next election I will have been a United States citizen for at least one month. I will be at least 18 years of age, and I will have resided in Pennsylvania and in my election district for at least 30 days; (2) I am legally qualified to vote.

X
Date:

AND I HEREBY AFFIRM THAT the information I have provided in this Print Your Name Below registration declaration is true. I understand that this registration declaration will be accepted for all purposes as the equivalent of an affidavit; and if the registration contains a materially false statement, I will be subject to penalties for perjury.
- not necessary if you are 12 (If ifavailable not know your number.) registering to vote for the first time or you do

/

/

Voter Identification Number

• For more information on voting, please visit our educational web site: www.VotesPA.com. If you • hotlinedo not receive your voter ID card in the mail within two weeks, call your county voter registration or our toll-free 1-800-552-VOTE. are interested county • If you registration in becoming a poll worker or a bilingual interpreter on Election Day, please check the boxes. Your will contact you. voter
your e-mail address is • Although providingmissing information onoptional, it is a quick and easy way for your county voter registration you in case there is your registration form:

13 Do you require assistanceYes when voting?

Reason for assistance: No

I would like to be a poll worker on Election Day I would like to be a bilingual interpreter on Election Day Specify Language:

to contact

IDENTIFICATION WHEN YOU VOTE

residence.)

DSBE-600 2/09

To mail this application, write the address of the County Voter Registration Office in the proper area on the reverse side of this form.

ADDRESSES OF COUNTY VOTER REGISTRATION OFFICES

ADAMS COUNTY 111-117 BALTIMORE ST GETTYSBURG PA 17325-2312 (717) 337-9832 ALLEGHENY COUNTY 542 FORBES ST STE 609 P IT T S B U R G H PA 15219-29 13 (412) 350-4500 ARMSTRONG COUNTY 450 E. MARKET ST, STE 207 KITTANNING PA 16201 (724) 548-3222 BEAVER COUNTY 810 THIRD ST BEAVER PA 15009 (724) 728-5700 BEDFORD COUNTY 200 SOUTH JULIANA ST 3RD FLOOR BEDFORD PA 15522 (814) 623-4807 BERKS COUNTY 633 COURT ST READING PA 19601 (610) 478-6490 BLAIR COUNTY 423 ALLEGHENY ST STE 043 HOLLIDAYSBURG PA 16648-2022 (814) 693-3150 BRADFORD COUNTY 301 MAIN ST TOWANDA PA 18848-1878 (570) 265-1717 BUCKS COUNTY 55 E COURT ST DOYLESTOWN PA 18901-4318 (215) 348-6163 BUTLER COUNTY PO BOX 1208 BUTLER PA 16003-1208 (724) 284-5308 CAMBRIA COUNTY 200 S CENTER ST EBENSBURG PA 15931 (814) 472-1464

COLUMBIA COUNTY 35 W MAIN ST PO BOX 380 BLOOMSBURG PA 17815-0380 (570) 389-5640 CRAWFORD COUNTY 903 DIAMOND PARK MEADVILLE PA 16335-2678 (814) 333-7306 CUMBERLAND COUNTY 310 ALLEN RD CARLISLE PA 17013-3044 (717) 240-6385 DAUPHIN COUNTY PO BOX 1295 HARRISBURG PA 17108-1295 (717) 780-6360 DELAWARE COUNTY GOVT CENTER BLDG 201 W FRONT ST MEDIA PA 19063-2728 (610) 891-4659 ELK COUNTY 300 CENTER ST PO BOX 448 RIDGWAY PA 15853-0448 (814) 776-5337 ERIE COUNTY 140 W 6TH ST RM 105 ERIE PA 16501-1096 (814) 451-6276

LEBANON COUNTY 400 S 8TH ST LEBANON PA 17042-6794 (717) 274-2801 EXT 4428 LEHIGH COUNTY 17 S 7TH ST ALLENTOWN PA 18101-2401 (610) 782-3194
LUZERNE COUNTY 20 N PENNSYLVANIA AVE STE 207 WILKES-BARRE PA 18701-3505 (570) 825-1715 LYCOMING COUNTY 48 W THIRD ST WILLIAMSPORT PA 17701-0536 (570) 327-2267 MCKEAN COUNTY 500 W MAIN ST COURTHOUSE SMETHPORT PA 16749 (814) 887-3203

SCHUYLKILL COUNTY 420 N C E NT R E S T POTTSVILLE PA 17901 (570) 628-1467 SNYDER COUNTY PO BOX 217 MIDDLEBURG PA 17842-0217 (570) 837-4209 SOMERSET COUNTY 300 N CENTER AVE STE 340 SOMERSET PA 15501 (814) 445-1549
UNION COUNTY 155 N 15TH ST LEWISBURG PA 17837-8822 (570) 524-8681 VENANGO COUNTY 1174 ELK ST PO BOX 831 FRANKLIN PA 16323-0831 (814) 432-9514 WARREN COUNTY 204 4TH AVE WARREN PA 16365-2399 (814) 728-3406 WASHINGTON COUNTY 100 W BEAU ST RM 206 WASHINGTON PA 15301 (724) 228-6750 WAYNE COUNTY 925 COURT ST HONESDALE PA 18431-1996 (570) 253-5978 WESTMORELAND COUNTY 2 N MAIN ST STE 109 GREENSBURG PA 15601 (724) 830-3150 WYOMING COUNTY 1 COURTHOUSE SQ TUNKHANNOCK PA 18657-1216 (570) 996-2226 YORK COUNTY 28 EAST MARKET ST YORK PA 17401-1579 (717) 771-9604

MERCER COUNTY 5 COURTHOUSE MERCER PA 16137-1227 (724) 662-3800 EXT 2240 MIFFLIN COUNTY 20 N WAYNE ST LEWISTOWN PA 17044 (717) 248-6571 MONROE COUNTY ONE QUAKER PLAZA RM 105 STROUDSBURG PA 18360-2170 (570) 517-3165 MONTGOMERY COUNTY COURTHOUSE PO BOX 311 NORRISTOWN PA 19404-0311 (610) 278-3280 MONTOUR COUNTY 29 MILL ST DANVILLE PA 17821 (570) 271-3000 NORTHAMPTON COUNTY 670 WOLF AVE E A S T O N PA 18042- 4343 (610) 559-3055 NORTHUMBERLAND COUNTY 609 MARKET ST SUNBURY PA 17801-2360 (570) 988-4208 PERRY COUNTY PO BOX 37 NEW BLOOMFIELD PA 17068-0037 (717) 582-2131 EXT 4110 PHILADELPHIA COUNTY 520 N DELAWARE AVE 5TH FL PHILADELPHIA PA 19123-4295 (215) 686-1591 PIKE COUNTY 506 BROAD ST MILFORD PA 18337-1535 (570) 296-3426 POTTER COUNTY 1 NORTH MAIN ST COUDERSPORT PA 16915 (814) 274-8467 SULLIVAN COUNTY PO BOX 157 LAPORTE PA 18626-0157 (570) 946-5201 SUSQUEHANNA COUNTY PO BOX 218 MAPLE ST MONTROSE PA 18801-0218 (570) 278-4600 EXT 220 TIOGA COUNTY 118 MAIN ST WELLSBORO PA 16901-0589 (570) 723-8230

FAYETTE COUNTY 22 E MAIN ST PUBLIC SERVICE BLDG UNIONTOWN PA 15401 (724) 430-1289 FOREST COUNTY 526 ELM ST BOX 3 TIONESTA PA 16353 (814) 755-3537 FRANKLIN COUNTY 157 LINCOLN WAY EAST CHAMBERSBURG PA 17201-2211 (717) 261-3886
FULTON COUNTY 116 W MARKET ST STE 203 MCCONNELLSBURG PA 17233 (717) 485-3691 GREENE COUNTY 93 E HIGH ST RM 102 WAYNESBURG PA 15370 (724) 852-5230 HUNTINGDON COUNTY 223 PENN ST COURTHOUSE HUNTINGDON PA 16652-1486 (814) 643-3091 INDIANA COUNTY 825 PHILADELPHIA ST INDIANA PA 15701-3934 (724) 465-3852 JEFFERSON COUNTY 155 MAIN ST JEFFERSON PLACE BROOKVILLE PA 15825-1269 (814) 849-1605 JUNIATA COUNTY BRIDGE ST PO BOX 68 MIFFLINTOWN PA 17059 (717) 436-7706 LACKAWANNA COUNTY 135 JEFFERSON AVE STE 100 SCRANTON PA 18503 (570) 963-6737 LANCASTER COUNTY 150 NORTH QUEEN ST STE 102 LANCASTER PA 17603-3562 (717) 299-8293 LAWRENCE COUNTY 430 COURT ST NEW CASTLE PA 16101-3593 (724) 656-2161

CAMERON COUNTY 20 E FIFTH ST EMPORIUM PA 15834-1469 (814) 486-2315 CARBON COUNTY 76 SUSQUEHANNA ST PO BOX 170 JIM THORPE PA 18229-0170 (570) 325-4801 CENTRE COUNTY 420 HOLMES ST BELLEFONTE PA 16823-1488 (814) 355-6703
CHESTER COUNTY 601 WESTTOWN RD STE 150 PO BOX 2747 WEST CHESTER PA 19380-0990 (610) 344-6410 CLARION COUNTY 421 MAIN ST STE 19 CLARION PA 16214-1093 (814) 226-4000 EXT 2205 CLEARFIELD COUNTY 230 E MARKET ST STE 108 CLEARFIELD PA 16830 (814) 765-2641 EXT 5996 CLINTON COUNTY 232 E MAIN ST GARDEN BLDG 3RD FL LOCK HAVEN PA 17745-1385 (570) 893-4019

For a listing of available county e-mail addresses, go to: www.VotesPA.com