12068 Newvoteformentereable

User Manual: 12068

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New York State Voter Registration Form

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.

Send or deliver this form

Fill out the form below and send it to your

county’s address on the back of this form,

or take this form to the ofﬁce of your County

Board of Elections.

Mail or deliver this form at least 25 days before

the election you want to vote in. Your county will

notify you that you are registered to vote.

Questions?

Call your County Board of Elections

listed on the back of this form or

1-800-FOR-VOTE (TDD/TTY Dial 711)

Find answers or tools on our website

www.elections.state.ny.us

Verifying your identity

We’ll try to check your identity before Election

Day, through the DMV number (driver’s license

number or non-driver ID number), or the last

four digits of your social security number,

which you’ll ﬁll in below.

If you do not have a DMV or social security

number, you may use a valid photo ID, a current

utility bill, bank statement, paycheck, government

check or some other government document that

shows your name and address. You may include

a copy of one of those types of ID with this form—

be sure to tape the sides of the form closed.

If we are unable to verify your identity before

Election Day, you will be asked for ID when

you vote for the ﬁrst time.

Información en español: si le interesa obtener este

formulario en español, llame al 1-800-367-8683

Last name

First name

Apt. Number

I need to apply for

an Absentee ballot (optional).

I would like to be an

Election Day worker (optional).

Middle Initial

Sufﬁx

City/Town/Village

Zip code

Afﬁdavit: I swear or afﬁrm that

• IamacitizenoftheUnitedStates.

• Iwillhavelivedinthecounty,cityorvillage

for at least 30 days before the election.

• Imeetallrequirementstoregister

to vote in New York State.

• Thisismysignatureormarkintheboxbelow.

• Theaboveinformationistrue,Iunderstandthat

if it is not true, I can be convicted and ﬁned up

to $5,000 and/or jailed for up to four years.

I do not have a New York State driver’s license or a Social Security number.

x x x – x x –

Last four digits of your Social Security number

Democratic party

Republican party

Conservative party

Working Families party

Independence party

Green party

Other

I do not wish to enroll in a party

Address(notP.O.box)

Your address was

Your previous state or New York State County was

Your name was

New York State County

Have you voted before? Yes No

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

Qualiﬁcations

9What year?

Address or P.O. box

P.O. Box

City/Town/Village

Birth date Y Y Y YD D

/ /

M M

4Sex M F

Telephone (optional)

– –

Sign

Date

Are you a citizen of the U.S.? Yes No

If you answer No, you cannot register to vote.

If you answer No, you cannot register to vote unless you will be 18 by the end of the year.

Will you be 18 years of age or

older on or before election day? Yes No

New York State DMV number

Rev. 01/2011

It is a crime to procure a false registration or to furnish false information to the Board of Elections. Please print in blue or black ink.

For board use only

中文資料:若您有興趣索取中文資料表格,

請電: 1-800-367-8683

한국어: 한국어 양식을 원하시면

1-800-367-8683 으로 전화 하십시오.

glue strip

Please select your New York State County

Address and stamp this section

Your address

Your County Board of Elections address (select from below)

Place

First-class

stamp

here

Before mailing

Remove tape,

fold and seal

Albany

32 North Russell Road

Albany, NY 12206

(518) 487-5060

Allegany

6 Schuyler St.

Belmont, NY 14813

(585) 268-9294

Broome

Government Plaza

44 Hawley St.

POBox1766

Binghamton, NY

13902

(607) 778-2172

Cattaraugus

302 Court St.

Little Valley, NY 14755

(716) 938-2400

Cayuga

10 Court St.

Auburn, NY 13021

(315) 253-1285

Chautauqua

7 North Erie St.

Mayville, NY 14757

(716) 753-4580

Chemung

378 South Main St.

POBox588

Elmira, NY 14902

(607) 737-5475

Chenango

5 Court St.

Norwich, NY 13815

(607) 337-1760

Clinton

Cnty Government Ctr.

137 Margaret St.

Ste. 104

Plattsburgh, NY 12901

(518) 565-4740

Columbia

401 State St.

Hudson, NY 12534

(518) 828-3115

Cortland

County Ofﬁce Bldg.

60 Central Ave.

Room 102

Cortland, NY 13045

(607) 753-5032

Delaware

3 Gallant Ave.

Delhi, NY 13753

(607) 746-2315

Dutchess

47 Cannon St.

Poughkeepsie, NY

12601

(845) 486-2473

Erie

134 W. Eagle St.

Buffalo, NY 14202

(716) 858-8891

Essex

7551 Court St.

POBox217

Elizabethtown, NY

12932

(518) 873-3474

Franklin

355 West Main St.

Ste. 161

Malone, NY 12953

(518) 481-1663

Fulton

2714 St. Hwy 29

Ste. 1

Johnstown, NY 12095

(518) 736-5526

Genesee

County Building #1

15 Main St.

POBox284

Batavia, NY 14021

(585) 344-2550

Greene

411 Main St.

Ste. 437

Catskill, NY 12414

(518) 719-3550

Hamilton

Rte. 8

POBox175

Lake Pleasant, NY

12108

(518) 548-4684

Herkimer

109 Mary St.

Ste. 1306

Herkimer, NY 13350

(315) 867-1102

Jefferson

175 Arsenal St.

Watertown, NY 13601

(315) 785-3027

Lewis

7660 N. State St.

Lowville, NY 13367

(315) 376-5329

Livingston

County Govt. Ctr.

6 Court St.

Room 104

Geneseo, NY 14454

(585) 243-7090

Madison

County Ofﬁce Bldg.

N. Court St.

POBox666

Wampsville, NY 13163

(315) 366-2231

Monroe

39 Main St. W.

Rochester, NY 14614

(585) 753-1550

Montgomery

Old Courthouse

9 Park St.

POBox1500

Fonda, NY 12068

(518) 853-8180

Nassau

240 Old Country Rd.

5th Fl.

Mineola, NY 11501

(516) 571-2411

Niagara

111 Main St.

Ste. 100

Lock port, NY 14094

(716) 438-4040

Oneida

Union Station

321 Main St.

3rd Fl.

Utica, NY 13501

(315) 798-5765

Onondaga

100 Erie Blvd West

Syracuse, NY 13204

(315) 435-3312

Ontario

74 Ontario St.

Canandaigua, NY

14424

(585) 396-4005

Orange

25 Court Lane

POBox30

Goshen, NY 10924

(845) 291-2444

Orleans

County Admin. Bldg.

14016 State Rte. 31

Albion, NY 14411

(585) 589-3274

Oswego

185 E. Seneca St.

Box9

Oswego, NY 13126

(315) 349-8350

Otsego

Ste. 2

140 County Hwy. 33W

Cooperstown, NY

13326

(607) 547-4247

Putnam

25 Old Route 6

Carmel, NY 10512

(845) 808-1300

Rensselaer

Ned Pattison

Government Ctr.

1600 Seventh Ave.

Troy, NY 12180

(518) 270-2990

Rockland

11 New Hempstead Rd.

New City, NY 10956

(845) 638-5172

St. Lawrence

48 Court St.

Canton, NY 13617

(315) 379-2202

Saratoga

50 W. High St.

Ballston Spa, NY

12020

(518) 885-2249

Schenectady

388 Broadway, Ste. E

Schenectady, NY

12305

(518) 377-2469

Schoharie

County Ofﬁce Bldg.

284 Main St.

POBox99

Schoharie, NY 12157

(518) 295-8388

Schuyler

County Ofﬁce Bldg.

105 9th St., Unit 13

Watkins Glen, NY

14891

(607) 535-8195

Seneca

One DiPronio Dr.

Waterloo, NY 13165

(315) 539-1760

Steuben

3E.PulteneySq.

Bath, NY 14810

(607) 664-2260

Suffolk

POBox700

Yaphank Ave.

Yaphank, NY 11980

(631) 852-4500

Sullivan

Gov’t. Ctr.

100 North St.

POBox5012

Monticello, NY 12701

(845) 807-0400

Tioga

County Ofﬁce Bldg.

56 Main St.

Owego, NY 13827

(607) 687-8261

Tompkins

CourtHouseAnnex

128 E. Buffalo St.

Ithaca, NY 14850

(607) 274-5522

Ulster

284 Wall St.

Kingston, NY 12401

(845) 334-5470

Warren

Cnty. Municipal Ctr.

1340 St. Rte. 9

Lake George, NY

12845

(518) 761-6456

Washington

383 Broadway

Fort Edward, NY

12828

(518) 746-2180

Wayne

157MontezumaSt.Ext.

POBox636

Lyons, NY 14489

(315) 946-7400

Westchester

25 Quarropas St.

White Plains, NY

10601

(914) 995-5700

Wyoming

4 Perry Ave.

Warsaw, NY 14569

(585) 786-8931

Yates

Ste. 1124

417 Liberty St.

Penn Yan, NY 14527

(315) 536-5135

New York City

ExecutiveOfces

32 Broadway, 7th Fl.

New York, NY

10004

(212) 487-5300

Eye color

If you would like to be an organ and tissue donor, you may enroll in

the NYS Department of Health (DOH) Donate Life™ Registry online

at www.nyhealth.gov or provide your name and address below.

You will receive a conﬁrmation letter from DOH, which will also

provide you an opportunity to limit your donation.

By signing below,

you certify that you are:

• 18yearsofageorolder;

• consentingtodonateallofyourorgansand

tissues for transplantation, research, or both;

• authorizingtheBoardofElectionstoprovide

your name and identifying information to

DOH for enrollment in the Registry;

• andauthorizingDOHtoallowaccesstothisin-

formation to federally regulated organ procure-

ment organizations and NYS-licensed tissue

and eye banks and hospitals upon your death.

(Optional) Register to donate your organs and tissues

Last name

First name

Address

Apt. Number

Sex M F

City

Height

Ft.

In.

Sign Date

Sufﬁx

Apt. Number

Middle Initial

Zip code

Birth date Y Y Y YD D

/ /

M M

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