Fillable Printable New York State Voter Registration Form

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.ny.gov

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 rst time.

Last name

First name

Apt. Number

I need to apply for an Absentee ballot.

I would like to be an Election Day worker.

Middle Initial

Sufx

City/Town/Village

Zip code

Afdavit: I swear or afrm 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

Green party

Working Families party

Independence party

Women’s Equality party

Reform party

Other

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

Items 6 & 7 are optional

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

Identication

You must make 1 selection

For questions, please refer to

Verifying your identity above.

Political party

You must make 1 selection

Political party enrollment is

optional but that, in order to

vote in a primary election of

a political party, a voter must

enroll in that political party,

unless state party rules allow

otherwise.

Optional questions

Qualications

What year?

Address or P.O. box

P.O. Box

City/Town/Village

Birth date

Y Y Y YD DM M

/ /

Phone

– –

Sex M F

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. 02/2015

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

যদি আপদি এই ফর বাংলাতে পপতে চাি োহতল

1-800-367-8683 িতে পফাি কি

Información en español: si le interesa obtener este

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

한국어: 한국어 양식을 원하시면

1-800-367-8683 으로 전화 하십시오.

I wish to enroll in a political party

I do not wish to enroll in a political party

No party

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

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

Sufx

Apt. Number

Middle Initial

Zip code

Birth date

Y Y Y YD D

/ /

M M

New York City

32 Broadway, 7th Fl.

New York, NY 10004

(212) 487-5300

Albany

32 North Russell Road

Albany, NY 12206

(518) 487-5060

Allegany

6 Schuyler St.

Belmont, NY 14813

(585) 268-9294

Broome

Government Plaza

60 Hawley St.

PO Box 1766

Binghamton, NY

13902

(607) 778-2172

Cattaraugus

207 Rock City St.

Suite 100

Little Valley, NY 14755

(716) 938-2400

Cayuga

157 Genesee St.

(Basement)

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.

Ste. 104

137 Margaret St.

Plattsburgh, NY 12901

(518) 565-4740

Columbia

401 State St.

Hudson, NY 12534

(518) 828-3115

Cortland

112 River St.

Suite 1

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

Lockport, NY 14094

(716) 438-4040

Oneida

Union Station

321 Main St.

3rd Fl.

Utica, NY 13501

(315) 798-5765

Onondaga

1000 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

14012 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

Yaphank Ave.

PO Box 700

Yaphank, NY 11980

(631) 852-4500

Sullivan

Gov’t. Ctr.

100 North St.

PO Box 5012

Monticello, NY 12701

(845) 807-0400

Tioga

1062 State Rte. 38

P.O. Box 306

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.

3rd Floor

Human Serv. Bldg

1340 St. Rte. 9

Lake George, NY

12845

(518) 761-6456

Washington

383 Broadway

Fort Edward, NY

12828

(518) 746-2180

Wayne

7376 State Rte. 31

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