Fillable Printable Virginia Voter Registration Application Form - Virginia

Virginia Voter Registration Application Form - Virginia

Privacy Act Notice: Article II, Section 2 of the Constitution of Virginia (1971) requires that a person registering to vote provide his or her social

security number, if any. Therefore, if you do not provide your social security number, your application for voter registration will be denied.

Section 7 of the Federal Privacy Act (Public Law Number 93-579) allows the Commonwealth to enforce this requirement, but also requires

that you be advised that state and local voting officials will use the social security number as a unique identifier to ensure that no person is

registered in more than one place. This registration card will only be open to inspection by the public if the social security number is removed.

Your social security number will appear on reports produced only for official use by voter registration and election officials, and for jury

selection purposes by courts, and all lawful governmental purposes.

Bilingual Election Requirements: Section 203 of the Voting Rights Act of 1965 (52 USC § 10503) mandates that a state or political subdivision

must provide language assistance to voters if more than five (5) percent or more than 10,000 of voting age citizens are members of a single-

language minority group and are limited-English proficient; and the illiteracy rate of such language minority citizens in the political subdivision

is higher than the national illiteracy rate. Only those localities in Virginia meeting this threshold are required to provide bilingual language

assistance for qualifying languages under Section 203. Localities covered: Fairfax County (Spanish).

WARNING: INTENTIONALLY VOTING MORE THAN ONCE IN AN ELECTION OR MAKING A MATERIALLY FALSE STATEMENT ON THIS FORM

CONSTITUTES THE CRIME OF ELECTION FRAUD, WHICH IS PUNISHABLE UNDER VIRGINIA LAW AS A FELONY. VIOLATORS MAY BE

SENTENCED TO UP TO 10 YEARS IN PRISON, OR UP TO 12 MONTHS IN JAIL AND/OR FINED UP TO $2,500.

Virginia

Voter Registration

Application Form

You are not officially registered to vote until this application is approved. You should receive an information

card or other correspondence in the mail. If you do not receive this acknowledgment within 30 days after

mailing this form, please contact your city or county voter registration office or the Department of Elections. If

you are already registered to vote with your current name and address, you do not need to re-register. If you

have any questions regarding your voter registration status, please call your local Voter Registration Office.

Instructions

Address

Requirements

Protected Voter

Requirements

All applicants must provide a street address/description of their physical dwelling place. If that address is

not serviced by the U.S. Postal Service, the applicant should also list a mailing address.

To legally qualify to non-publish your residence address on voter lists requires that you meet certain

statutory requirements. Your application must claim one of four reason codes:

· LEO: active or retired law enforcement officer, judge, U.S. or Virginia Attorney General attorney;

· CPO: have a court issued protective order for your benefit;

· TSC: have a complaint with law enforcement about being threatened or stalked (must attach complaint); or

· ACP: registered with the Virginia Attorney General’s Address Confidentiality Program.

An eligible applicant who wants to non-publish the applicant’s residence address in voter lists must also

provide an alternative post office box mailing address within Virginia to be used on the voter lists.

Mailing

Instructions

· Place completed application in an envelope.

· Write your name and return address on the envelope.

· Write the address of the voter registration office for the county or city where you live:

· Must be postmarked at least 22 days before the next Primary or General Election in which you plan to vote.

VA-NVRA-1 07/15

Accomack County

PO Box 97

Accomac, VA 23301-0097

(757) 787 • 2935

Albemarle County

PMB 404, 536 Pantops Center

Charlottesville, VA 22911

(434) 972 • 4173

Alexandria City

132 North Royal St, Ste. 100

Alexandria, VA 22314-3283

(703) 746 • 4050

Alleghany County

110 Rosedale Ave, Ste. D

Covington, VA 24426-1294

(540) 965 • 1690

Amelia County

PO Box 481

Amelia, VA 23002-0481

(804) 561 • 3460

Amherst County

PO Box 550

Amherst, VA 24521-0550

(434) 946 • 9315

Appomattox County

PO Box 8

Appomattox, VA 24522-0008

(434) 352 • 5302

Arlington County

2100 Clarendon Blvd, Ste. 320

Arlington, VA 22201-5400

(703) 228 • 3456

Augusta County

PO Box 590

Verona, VA 24482-0590

(540) 245 • 5656

Bath County

PO Box 157

Warm Springs, VA 24484-0157

(540) 839 • 7266

Bedford County

County Admin Building

122 East Main St, Ste. 204

Bedford, VA 24523-2000

(540) 586 • 7649

Bland County

PO Box 535

Bland, VA 24315-0535

(276) 688 • 4441

Botetourt County

PO Box 62

Fincastle, VA 24090-0062

(540) 473 • 8235

Bristol City

300 Lee St

Bristol, VA 24201-4327

(276) 645 • 7318

Brunswick County

100 Tobacco St, Rm. 103

Lawrenceville, VA 23868-1823

(434) 848 • 4414

Buchanan County

PO Box 975

Grundy, VA 24614-0975

(276) 935 • 6534

Buckingham County

PO Box 222

Buckingham, VA 23921-0222

(434) 969 • 4304

Buena Vista City

2039 Sycamore Ave

Buena Vista, VA 24416-3133

(540) 261 • 8605

Campbell County

PO Box 103

Rustburg, VA 24588-0103

(434) 332 • 9579

Caroline County

PO Box 304

Bowling Green, VA 22427-0304

(804) 633 • 9083

Carroll County

Governmental Center

605-3 Pine St, B 110

Hillsville, VA 24343-1404

(276) 730 • 3035

Charles City County

PO Box 146

Charles City, VA 23030-0146

(804) 652 • 4606

Charlotte County

PO Box 118

Charlotte CH, VA 23923-0118

(434) 542 • 5856

Charlottesville City

PO Box 911

Charlottesville, VA 22902-0911

(434) 970 • 3250

Chesapeake City

411 Cedar Rd

Chesapeake, VA 23322-5566

(757) 277 • 9797

Chesterfield County

PO Box 1690

Chesterfield, VA 23832-1690

(804) 748 • 1471

Clarke County

PO Box 555

Berryville, VA 22611-0555

(540) 955 • 5168

Colonial Heights City

PO Box 3401

Colonial Heights, VA 23834-9001

(804) 520 • 9277

Covington City

515 E. Pine St

Covington, VA 24426-1534

(540) 965 • 6380

Craig County

PO Box 8

New Castle, VA 24127-0008

(540) 864 • 6190

Culpeper County

151 North Main St, Ste. 301

Culpeper, VA 22701

(540) 825 • 0652

Cumberland County

PO Box 125

Cumberland, VA 23040-0008

(804) 492 • 4504

Danville City

515 Main St

Danville, VA 24541-1317

(434) 799 • 6560

Dickenson County

PO Box 1306

Clintwood, VA 24228-1306

(276) 926 • 1620

Dinwiddie County

PO Box 365

Dinwiddie, VA 23841-0365

(804) 469 • 4500 option 7

Emporia City

PO Box 1092

Emporia, VA 23847-1092

(434) 634 • 9533

Essex County

PO Box 1561

Tappahannock, VA 22560-1561

(804) 443 • 4611

Fairfax County

12000 Govt Ctr Pkwy, Ste. 323

Fairfax, VA 22035-0081

(703) 222 • 0776

Fairfax City

Sisson House

10455 Armstrong St

Fairfax, VA 22030-3640

(703) 385 • 7890

Falls Church City

300 Park Ave, Rm. 101E

Falls Church, VA 22046-3332

(703) 248 • 5085

Fauquier County

32 Waterloo St, Ste. 207

Warrenton, VA 20186-3238

(540) 422 • 8290

Floyd County

100 East Main St, Rm. 302

Floyd, VA 24091-2101

(540) 745 • 9350

Fluvanna County

PO Box 44

Palmyra, VA 22963-0044

(434) 589 • 3593

Franklin County

1255 Franklin St, Ste. 106

Rocky Mount, VA 24151-1289

(540) 483 • 3025

Franklin City

PO Box 42

Franklin, VA 23851-0042

(757) 562 • 8545

Frederick County

107 North Kent St, Ste. 102

Winchester, VA 22601-5039

(540) 665 • 5660

Fredericksburg City

Executive Plaza

601 Caroline St, Ste. 500-A

Fredericksburg, VA 22401

(540) 372 • 1030

Galax City

PO Box 1045

Galax, VA 24333-1045

(276) 236 • 7509

Giles County

201 N. Main St, Ste. 1

Pearisburg, VA 24134-1611

(540) 921 • 2802

Gloucester County

PO Box 208

Gloucester, VA 23061-0208

(804) 693 • 3659

Goochland County

PO Box 1013

Goochland, VA 23063-1013

(804) 556 • 5803

Grayson County

PO Box 449

Independence, VA 24348-0449

(276) 773 • 2842

Greene County

PO Box 341

Stanardsville, VA 22973-0341

(434) 985 • 5213

Greensville County

PO Box 1092

Emporia, VA 23847-1092

(434) 348 • 4228

Halifax County

PO Box 400

Halifax, VA 24558-0400

(434) 476 • 3322

Hampton City

1919 Commerce Dr, Ste. 280

Hampton, VA 23666

(757) 727 • 6218

Hanover County

PO Box 419

Hanover, VA 23069-0419

(804) 365 • 6080

Harrisonburg City

PO Box 20031

Harrisonburg, VA 22801-7531

(540) 432 • 7707

Henrico County

PO Box 90775

Henrico, VA 23273-0775

(804) 501 • 4347

Henry County

PO Box 7

Collinsville, VA 24078-0007

(276) 638 • 5108

Highland County

PO Box 386

Monterey, VA 24465-0386

(540) 468 • 2013

Hopewell City

309 North 2nd Ave

Hopewell, VA 23860-2704

(804) 541 • 2232

Isle of Wight County

PO Box 77

Isle of Wight, VA 23397-0077

(757) 365 • 6230

James City County

PO Box 3567

Williamsburg, VA 23187-3567

(757) 253 • 6868

King & Queen County

PO Box 56

King & Queen CH, VA 23085-

0056

(804) 785 • 5980

King George County

PO Box 1359

King George, VA 22485-1359

(540) 775 • 9186

King William County

PO Box 173

King William, VA 23086-0173

(804) 769 • 4952

Lancaster County

PO Box 159

Lancaster, VA 22503-0159

(804) 462 • 5277

Lee County

PO Box 363

Jonesville, VA 24263-0363

(276) 346 • 7780

Lexington City

PO Box 922

Lexington, VA 24450-0922

(540) 462 • 3706

Loudoun County

750 Miller Drive, SE, Ste. C

Leesburg, VA 20175-8916

(703) 777 • 0380

Louisa County

PO Box 220

Louisa, VA 23093-0220

(540) 967 • 3427

Lunenburg County

160 Courthouse Sq

Lunenburg, VA 23952-9999

(434) 696 • 3071

Lynchburg City

3236 Odd Fellows Rd

Lynchburg, VA 24501

(434) 477 • 5999

Madison County

PO Box 267

Madison, VA 22727-0267

(540) 948 • 6533

Manassas City

9025 Center St

Manassas, VA 20110-5403

(703) 257 • 8230

Manassas Park City

City Hall. 1 Park Center Ct

Manassas Park, VA 20111-2395

(703) 335 • 8806

Martinsville City

PO Box 1323

Martinsville, VA 24114-1323

(276) 403 • 5122

Mathews County

PO Box 328

Mathews, VA 2310

(804) 725 • 3200

Mecklenburg County

PO Box 436

Boydton, VA 23917-0436

(434) 738 • 6191

Middlesex County

PO Box 358

Saluda, VA 23149-0358

(804) 758 • 4420

Montgomery County

755 Roanoke St, Ste. 1F

Christiansburg, VA 24073-3175

(540) 382 • 5741

Nelson County

PO Box 292

Lovingston, VA 22949-0292

(434) 263 • 4068

New Kent County

PO Box 128

New Kent, VA 23124-0128

(804) 966 • 9699

Newport News City

2400 Washington Ave

Newport News, VA 23607-4305

(757) 926 • 8683

Norfolk City

PO Box 1531

Norfolk, VA 23501-1531

(757) 664 • 4353

Northampton County

PO Box 510

Eastville, VA 23347-0510

(757) 678 • 0480

Northumberland County

PO Box 84

Heathsville, VA 22473-0084

(804) 580 • 4655

Norton City

PO Box 225

Norton, VA 24273-0225

(276) 679 • 1162

Nottoway County

PO Box 24

Nottoway, VA 23955-0024

(434) 645 • 8148

Orange County

146 Madison Rd, Ste. 204

Orange, VA 22960-1449

(540) 672 • 5262

Page County

551 Mechanic St

Luray, VA 22835-1820

(540) 743 • 3986

Patrick County

PO Box 635

Stuart, VA 24171-0635

(276) 694 • 7206

Petersburg City

PO Box 1031

Petersburg, VA 23804-1031

(804) 733 • 8071

Pittsylvania County

110 Old Chatham Elementary Ln

Chatham, VA 24531

(434) 432 • 7971

Poquoson City

500 City Hall Ave, Rm. 139

Poquoson, VA 23662-1996

(757) 868 • 3070

Portsmouth City

801 Crawford St,1st Fl

Portsmouth, VA 23704-3822

(757) 393 • 8644

Powhatan County

3834 Old Buckingham Rd, Ste. G

Powhatan, VA 23139-7051

(804) 598 • 5604

Prince Edward County

PO Box J

Farmville, VA 23901

(434) 392 • 4767

Prince George County

PO Box 34

Prince George, VA 23875-0034

(804) 722 • 8748

Prince William County

9250 Lee Ave, Suite 1

Manassas, VA 20110-5554

(703) 792 • 6470

Pulaski County

87 Commerce St.

Pulaski, VA 24301-5045

(540) 980 • 2111

Radford City

619 2nd St

Radford, VA 24141

(540) 731 • 3639

Rappahannock County

PO Box 236

Washington, VA 22747-0236

(540) 675 • 5380

Richmond County

PO Box 1000

Warsaw, VA 22572-1000

(804) 333 • 4772

Richmond City

PO Box 61037

Richmond, VA 23261-1037

(804) 646 • 5950

Roanoke County

PO Box 20884

Roanoke, VA 24018-0089

(540) 772 • 7500

Roanoke City

215 Church Ave SW, Ste. 109

Roanoke, VA 24011-1518

(540) 853 • 2281

Rockbridge County

150 S. Main St

Lexington, VA 24450

(540) 463 • 7203

Rockingham County

20 E. Gay St

Harrisonburg, VA 22802-4108

(540) 564 • 3055

Russell County

PO Box 383

Lebanon, VA 24266-0383

(276) 889 • 8006

Salem City

PO Box 203

Salem, VA 24153-0203

(540) 375 • 3034

Scott County

PO Box 1892

Gate City, VA 24251-3417

(276) 386 • 3843

Shenandoah County

600 N. Main St, Ste. 103

Woodstock, VA 22664

(540) 459 • 6195

Smyth County

121 Bagley Cir, Ste. 108

Marion, VA 24354

(276) 783 • 4511

Southampton County

PO Box 666

Courtland, VA 23837-0666

(757) 653 • 9280

Spotsylvania County

PO Box 133

Spotsylvania, VA 22553-0133

(540) 507 • 7380

Stafford County

PO Box 301

Stafford, VA 22555-0301

(540) 658 • 4000

Staunton City

PO Box 58

Staunton, VA 24402-0058

(540) 332 • 3840

Suffolk City

PO Box 1966

Suffolk, VA 23439-1966

(757) 514 • 7750

Surry County

PO Box 264

Surry, VA 23883-0264

(757) 294 • 5213

Sussex County

PO Box 1302

Sussex, VA 23884-0302

(434) 246 • 1047

Tazewell County

PO Box 201

Tazewell, VA 24651-0201

(276) 385 • 1305

Virginia Beach City

PO Box 6247

Virginia Beach, VA 23456-0247

(757) 385 • 8683

Warren County

220 North Commerce Ave,

Ste. 700

Front Royal, VA 22630

(540) 635 • 4327

Washington County

1 Government Ctr Pl, Suite A

Abingdon, VA 24211-7466

(276) 676 • 6227

Waynesboro City

250 S. Wayne Ave, Ste. 205

Waynesboro, VA 22980

(540) 942 • 6620

Westmoreland County

PO Box 354

Montross, VA 22520-0354

(804) 493 • 8898

Williamsburg City

PO Box 3538

Williamsburg, VA 23187-3538

(757) 220 • 6157

Winchester City

107 N. East Lane

Winchester, VA 22601-5072

(540) 545 • 7910

Wise County

PO Box 309

Wise, VA 24293-0309

(276) 328 • 8331

Wythe County

45 South Fourth St, Ste. 101

Wytheville, VA 24382-2598

(276) 223 • 6038

York County

PO Box 451

Yorktown, VA 23690-0451

(757) 890 • 3440

Voter Registration Offices

(General Registrar)

7/01/2015

VA-NVRA-1 07/15

* Have you ever been convicted of a felony? YES NO

State where convicted

If YES, have your voting rights been restored? YES NO If YES, when restored?

/ /

D D

Y Y Y

/ /

D D

Y Y Y

/ /

D D

Y Y Y

/ /

D D

Y Y Y

/ /

D D

Y Y Y

* Are you a citizen of the United States

of America? YES NO

* Will you be at least 18 years of age on or before

the next General Election day?

YES NO

If you checked “NO” in response to either of

these questions, do not complete this form.

* Social Security Number

Male Female

* Date of Birth

* Last Name * First Name *

Full Middle or Maiden Name

Daytime Telephone Number

* Residence (Permanent) Home Address City/TownApt/Unit/Lot/Rm/Ste Zip Code

If Rural Address or Homeless, please describe where you reside

Mailing Address (if different)/Virginia P.O.Box or Uniformed Service Address, if applicable (include Zip Code)

Name of City or County of Residence

* Gender

Registration Statement: I swear/affirm, under felony penalty for making willfully false material statements or entries, that the

information provided on this form is true. I authorize the cancellation (entered in Box 7 below) of my current registration and I have

read the Privacy Act Notice on the front of this form.

If applicant is unable to sign due to a physical disability, write the name/address of person who assisted. (Required).

Virginia Voter Registration Application Form

· Be a United States citizen

· Be a resident of Virginia

· Be 18 years old by the next general election

*Previous Voter Registration Information – Commonwealth of Virginia

No, I am not currently registered to vote in Virginia or another state.

Yes, I am registered to vote at another address in Virginia or in another state. If YES, the information below must be completed:

Full Name as Registered

Address at which you were previously registered to vote

City/Town State Zip Code

City/County/Town of Residence (if applicable). This cancellation information will be sent to the county or city and state you entered above.

· Have had your voting rights restored if you have ever been convicted of a felony

· Have had your capacity restored if you have ever been declared mentally

incapacitated in a Circuit Court

To register to vote in

Virginia, you must:

Suffix (Jr., Sr., III, Etc.)

Protected Voter Code if applicable. See instructions.

I’m interested in being an Election Official on Election Day. Please send me information.

Check if you have a disability that requires

someone to assist you in order to vote.

E-mail address

* Signature (or mark if unable to sign)

Social Security Number

(last 4 digits required)

Use this form to register to vote in Virginia or report a change in name or address. If you are already registered with your current name and

address, you do not need to re-register.

None

* Have you ever been judged mentally incapacitated? YES NO

If YES, has court restored you to capacity?

YES NO If YES, when restored?

None

Date of Birth

City or County:

Identification Requirement

For Registration: If you are registering for the first time by mail, federal law (the Help America Vote Act) requires you to provide identification the first time you vote in

a federal election. Please enclose a copy of one of the following documents that shows your name and address with your application: (1) current and valid photo ID, (2)

current utility bill, (3) bank statement, (4) government check, (5) paycheck, or (6) other government document. If eligible to vote absentee by mail, your mailed absentee

ballot will not be counted unless the required identification has been provided to your local electoral board no later than noon on the Friday following the election.

For Voting: Virginia law requires you also to provide photo identification when you vote in person. An information card or other correspondence confirming your

registration does not qualify as photo identification. For information on other types of qualified identification, or how to obtain a Voter Photo Identification card, please

visit: elections.virginia.gov/voterID or call toll free at (800) 552-9745

TTY: 711.

Starred (*) items are required. If you do not complete all of the items that are marked with *, your application may be denied. Once your local registrar

approves your application, you will receive a confirmation by mail.

VA-NVRA-1 07/15

/ /

D D

Y Y Y

For Office Use Only

New Last Name New First, Middle/Maiden Name and Suffix

Date changed

Other changes New PCT Authorized by Date changed

Deceased

Out of State

Personal Request

Convicted of a Felony

Judged Incapacitated

Error Deleted

NVRA Cancel

Transferred Out

Re-Registered

Inactive Status

Reactivated

Notes

Registration date PCT Town code Date changed

Denial date & reason

Virginia Voter Registration Application Receipt

Name of group or individual

receiving application

Daytime telephone number of group

or individual receiving application

E-mail address

Name of Applicant

Date

No receipt is required for application

completed in the Voter Registration Office.

If you have not received a confirmation

within thirty (30) days of submitting a Voter

Registration Application, please contact

the Virginia Department of Elections.

Online: elections.virginia.gov

Voice: (800) 552 · 9745

TTY: 711

Richmond local: (804) 864 · 8901