VISA/I-Verify Registration Form

EVoteTechnology National Identification Card

For the 2024 U. S. Presidential Election Registration
NOTICE: Subscription to EVoteTechnology Newsletter included!

FIRST-TIME RENEWAL REPLACEMENT NEW REGION

REGISTRATION $10 “ $10 FEE $10 FEE

PLEASE TYPE OR PRINT LEGIBLY EvoteTechnology ID NUMBER: IF ANY

NAME Voter Registration No:
STREET ADDRESS
CITY STATE
ZIP CELL DATE OF BIRTH
E-MAIL
AGE GROUP TEAM AFFILIATION

EMERGENCY CONTACT PHONE

I certify that the information provided is correct and further agree that it must be verified. Any
falsification of information will result in disciplinary action, including suspension or banishment from
EVoteTechnololgy USA-sanctioned elections. I understand that valid authentication will be required as
proof of identity before I can participate in any Voter Integrity Society Association (VISA) sanctioned
activities.
I certify under penalty of perjury that all information and statement(s) made above are true to my
knowledge.

________________________________________
APPLICANT SIGNATURE AND DATE SIGNED

Printed Name of Person that Signed Above:________________________________________

WHAT TO SEND CHECKLIST

FIRST-TIME APPLICATIONS MUST INCLUDE
• VISA Registration Form
• Registration Fee
• Copy of Gov't issued photo ID, such as Drivers License or Passport
• Biometric Scan - (Palm Vein ScanProtocol)
• Registration as a legally registered voter in the state of residence.

RENEWALS MUST INCLUDE

• I-Verify Registration Form
• Registration Fee •
• Validation of Biometric Protocol Authentication
• Copy of Gov't issued photo ID, such as Drivers License or Passport

Make check payable to VISA • EVoteTechnology Registration.

Mail to: VISA • P.O. Box 19581• Overland Park, KS 66215 Phone: (816) 924-4671