Fillable Printable Voter Registration Application Form - Louisiana

Voter Registration Application Form - Louisiana

ACADIA

568 NW Court Circle

Crowley, LA 70526-4363

(337) 788-8841

ALLEN

P. O. Box 150

Oberlin, LA70655-0150

(337) 639-4966

ASCENSION

828 S. Irma Blvd., Rm. 205

Gonzales, LA 70737-3631

(225) 621-5780

ASSUMPTION

P. O. Box 578

Napoleonville, LA70390-0578

(985) 369-7347

AVOYELLES

312 N. Main St., Ste.E

Marksville, LA 71351-2409

(318) 253-7129

BEAUREGARD

P. O. Box 952

DeRidder,LA70634-0952

(337) 463-7955

BIENVILLE

P. O. Box 697

Arcadia, LA71001-0697

(318) 263-7407

BOSSIER

P. O. Box 635

Benton, LA71006-0635

(318) 965-2301

CADDO

P. O. Box 1253

Shreveport,LA71163-1253

(318) 226-6891

CALCASIEU

1000 Ryan St., Rm.7

Lake Charles, LA 70601-5250

(337) 721-4000

CALDWELL

P. O. Box 1107

Columbia, LA 71418-1107

(318) 649-7364

CAMERON

P. O. Box 1

Cameron, LA 70631-0001

(337) 775-5493

CATAHOULA

P. O. Box 215

Harrisonburg, LA 71340-0215

(318) 744-5745

CLAIBORNE

507 W. Main St., Ste. 1

Homer, LA 71040-3914

(318) 927-3332

CONCORDIA

4001 Carter St., Ste. K

Vidalia, LA 71373-3021

(318) 336-7770

DESOTO

105 Franklin St.

Mansfield, LA 71052-2046

(318) 872-1149

E. BATON ROUGE

222 St.LouisSt.,Rm.201

Baton Rouge, LA 70802-5860

(225) 389-3940

E. CARROLL

P. O. Box 708

Lake Providence,LA 71254-

0708

(318) 559-2015

E. FELICIANA

P. O. Box 488

Clinton, LA70722-0488

(225) 683-3105

EVANGELINE

200 Court St., Ste. 102

Ville Platte, LA 70586-4463

(337) 363-5538

FRANKLIN

Courthouse

6560 Main St.

Winnsboro, LA 71295-2750

(318) 435-4489

GRANT

Courthouse

200 Main St.

Colfax, LA 71417-1828

(318) 627-9938

IBERIA

300 S.Iberia St., Ste.110

New Iberia, LA 70560-4543

(337) 369-4407

IBERVILLE

P. O. Box 554

Plaquemine, LA 70765-0554

(225) 687-5201

JACKSON

500 E. CourtSt., Rm. 102

Jonesboro, LA 71251-3400

(318) 259-2486

JEFFERSON

P. O. Box10494

Jefferson, LA70181-0494

(504) 736-6191

JEFFERSON DAVIS

302 N. Cutting Ave.

Jennings, LA 70546-5361

(337) 824-0834

LAFAYETTE

1010 LafayetteSt., Ste. 313

Lafayette, LA 70501-6885

(337) 291-7140

LAFOURCHE

307 W. 4th St.

Thibodaux, LA70301-3105

(985) 447-3256

LASALLE

P. O. Box2439

Jena, LA 71342-2439

(318) 992-2254

LINCOLN

100 W. Texas Ave., Rm. 10

Ruston, LA 71270-4463

(318) 251-5110

LIVINGSTON

P. O. Box 968

Livingston, LA 70754-0968

(225) 686-3054

MADISON

100 N. Cedar St.

Tallulah,LA 71282-3892

(318) 574-2193

MOREHOUSE

129 N. FranklinSt.

Bastrop, LA71220-3815

(318) 281-1434

NATCHITOCHES

P. O. Box 677

Natchitoches, LA 71458-0677

(318) 357-2211

ORLEANS

1300 PerdidoSt., Rm. 1W23

New Orleans, LA 70112-2127

(504) 658-8300

OUACHITA

1650Desiard St., Ste. 125

Monroe, LA71201

(318) 327-1436

PLAQUEMINES

P. O. Box 989

Port Sulphur, LA 70083-0989

(504) 934-3620

POINTE COUPEE

211 E. MainSt., Flr. 2

New Roads, LA70760-3661

(225) 638-5537

RAPIDES

701 Murray St.

Alexandria, LA 71301-8099

(318) 473-6770

RED RIVER

P. O. Box 432

Coushatta, LA 71019-0432

(318) 932-5027

RICHLAND

P. O. Box 368

Rayville, LA 71269-0368

(318) 728-3582

SABINE

400 Capitol St., Rm. 107

Many, LA 71449-3099

(318) 256-3697

ST. BERNARD

8201 W. Judge Perez, Rm. 104

Chalmette, LA70043-1696

(504) 278-4231

ST. CHARLES

P. O. Box 315

Hahnville, LA 70057-0315

(985) 783-5120

ST. HELENA

P. O. Box 543

Greensburg, LA 70441-0543

(225) 222-4440

ST. JAMES

P. O. Box 179

Convent, LA70723-0179

(225) 562-2330

ST. JOHN

1801 W. AirlineHwy.

LaPlace, LA 70068-3344

(985) 652-9797

ST. LANDRY

P. O. Box 818

Opelousas, LA 70571-0818

(337) 948-0572

ST. MARTIN

415 SaintMartin St.

St. Martinville, LA70582-4549

(337) 394-2204

ST. MARY

500 Main St., Ste.301

Franklin, LA 70538-6144

(337) 828-4100,ext. 360

ST. TAMMANY

701 N. Columbia St.

Covington, LA 70433-2709

(985) 809-5500

TANGIPAHOA

P. O. Box 895

Amite, LA70422-0895

(985) 748-3215

TENSAS

P. O. Box 183

St. Joseph, LA 71366-0183

(318) 766-3931

TERREBONNE

8026 Main St., Ste. 101

Houma, LA70360

(985) 873-6533

UNION

P. O. Box 235

Farmerville, LA 71241-0235

(318) 368-8660

VERMILION

100 N. State St., Ste.120

Abbeville, LA 70510

(337) 898-4324

VERNON

P. O. Box 626

Leesville, LA 71496-0626

(337) 239-3690

WASHINGTON

Courthouse Bldg.

900 Washington St., #105

Franklinton, LA 70438

(985) 839-7850

WEBSTER

P. O. Box 674

Minden, LA 71058-0674

(318) 377-9272

W. BATON ROUGE

P. O. Box 31

Port Allen,LA 70767-0031

(225) 336-2421

W. CARROLL

P. O. Box 71

Oak Grove, LA71263-0071

(318) 428-2381

W. FELICIANA

P. O. Box 2490

St. Francisville, LA 70775-2490

(225) 635-6161

WINN

119 W. Main St.,Rm. 105

Winnfield, LA 71483-3238

(318) 628-6133

OFFICIAL USE ONLY

Address Change

__________________________________________________

Name Change

__________________________________________________

Party Change

__________________________________________________

Remarks

__________________________________________________

Circle One: PA MV RG SDA SS(Disability)

Received by: ___________________________________________

PLACE IN AN ENVELOPE AND MAIL TOYOUR

REGISTRAR OF VOTERS

USE THIS FORM TO:

1)register to vote 2)change your address3) request a name change4)change party affiliation

TO REGISTER TO VOTE AND BE ELIGIBLE TO VOTE YOU MUST: 1) be a United States citizen 2) be at least 17 ye

ars old to register but must be 18 years old to vote 3) not be under an

order of imprisonment for conviction of a felony 4) not be under a judgment of full interdiction or limited interdiction where your right to vote has been suspended 5) reside in the

state and parish

in which you seek to register and vote.

INSTRUCTIONS FOR COMPLETING THIS FORM:All information except your signature should be printed clearly in ink, preferably black, or typed. Fill in all boxes that apply to you.

Box 1:

Indicate whether you are a citizen of the United States of America.Indicate whether you will be 18 years of age on or before election day.

Box 2:

Provide full name.Do not use initials for middle or maiden name.

Box 3:

'Residence Address' means the address where you live and are registering to vote. If you claim a homestead exemption, you must list the address of that residence.

Do not use

a post office box for your 'Residence Address'.If you use a rural route and box number, draw a map in the space labeled 'Give Location.' Write in the names of the crossroads (stree

ts)

nearest to where you live. Draw an X to show where you live. Use a dot to show any schools, churches, stores or landmarks near where you live and write

the name of the landmark.

Check the box provided if mail isnotdelivered to your residence addressby the postoffice. Complete 'Mailing Address' only if it is different from the 'Residence Address'or if mail isnot

delivered to your residence address.

Boxes5 & 13:

You must provide your LAdriver's license numberor LA special identification card number

, if issued. If not issued, you must provide at least the last four digits of

yoursocial security number, if issued. The full social security number may be provided on a voluntary basis. If neither a social security number nor a LA driver's license number

or LA

special identification card number has been issued, and this form is submitted by mail, and you are registering to vote for the first time, in order to avoid ad

ditional identification

requirements for first time voters, attach either a) a copy of a current and valid photo identification

or b) a copy of a current utility bill, bank statement, government check, paycheck, or

other government document that shows your name and address.

Boxes 7, 11& 12

The items 'race/ethnic origin', 'email' and 'phone' are not required but are helpful.Email is protected from disclosure by law.

Box8:

If you do not complete this item, your party affiliation will be listed as'no party', unless you are

presently registered with a party affiliation and no change is being made today. If

you are not registering with a political party, circle ‘noparty’. The recognized political parties are Democrat, Green, Libertarian, Reform and Republican or you may speci

fy any other

party affiliation.

Box17

If you are using this form to request a change of name, you must print the name to be changed here.

Box 18:

Date and sign the card with your signature or mark.

If returned by mail, place in an envelopeand mail to the appropriate registrar of voters at the address found on the reverse sideof this card.

If you have not been issued a social security

number or Louisiana driver's license number,you must mail the required documentation with your application.

Your application or envelope must be postmarked 30 days prior to the first

election in which you seek to vote based on the residence listed on this application.

NOTE:

1. If you decline to register to vote, this fact will remain confidential and will be used only for voter registration purposes.

If you register to vote, the office where your application

was submitted will remain confidential and will be used only for voter registration purposes.2. Your social security number will also remain confidenti

al and is intended to be used for

voter registration purposes only.

QUESTIONS?

Call your Parish Registrar of VotersOR call the Department of State at

1-800-883-2805 or (225) 922-0900.

COMPLETE AND CHECK ALL APPLICABLE BOXES AND CUTHERE BEFORE MAILING.

LOUISIANAVOTER REGISTRATION

APPLICATIONLR-1 &1M, FORM #100

OFFICIAL USE ONLY

Wd __________Pct __________ Reg Type ___________ In/Out_________ REG # ___________________________________

1 Are you a citizen of the United States of America?YES



Will you be 18 years of age on or before election day?YES



If you checked ‘no’ in response to either of these questions, DO NOT COMPLETE THIS FORM.

2 NAME OF APPLICANT (PLEASE PRINTNAME)

GIVE LOCATION

LAST FIRST FULL MIDDLE OR MAIDEN

3 RESIDENCE ADDRESS (MUST BE ADDRESS WHERE YOU CLAIM HOMESTEAD EXEMPTION, IF ANY)

HOUSE OR APT. NO. & STREET (IF RURAL, ROUTE & BOX NO.) CITY OR TOWNSTATE ZIP

If NO mail delivery to residential

address, check here:

( )

MAILING ADDRESS, IF DIFFERENT

4DATE OF BIRTH

5* SOCIAL SECURITY # (CIRCLE ONE)

6SEX (CIRCLE ONE)

7** RACE / ETHNIC ORIGIN (CIRCLE ONE)

MONTH

DAY

YEAR

YES #____________________________________

MALE FEMALE

WHITE BLACK ASIAN HISPANIC AMER. INDIAN

OTHER: _____________________________________________

8PARTY AFFILIATION (CIRCLE ONE)

9APPLICANT’S PLACE OF BIRTH

10MOTHER’S MAIDEN NAME

DEM GRNLBTRFMREPNOPARTY

OTHER(SPECIFY) _________________________

CITY OR TOWN PARISH OR COUNTY STATE COUNTRY

11 **EMAIL

12** PHONE

13 LA DRIVER’S LICENSE / I.D. #

(CIRCLE ONE)

14Will you require assistance at the polls?

(CIRCLE

ONE)

HOME ( )

DAY ( )

YES #______________________________________

NO YES IFYES, GI

VE REASON :

15LAST RESIDENCE ADDRESS

16PLACE OF LAST REGISTRATION

17FORMER REGISTERED NAME, IF APPLICABLE

ADDRESS

PARISH OR COUNTY STATE

AFFIRMATION:I do hereby solemnly swear or affirm that I ama United States citizen, that I am at least 17 years old, thatI am not currently under an order of imprisonment for

conviction of a felony,thatI am not currently under a judgment of full interdiction or limited interdiction where my right to vote has been suspended, that I am a bona fide resident of this

state and parish, and that the facts given by me on this application are true to the best of my knowledge and belief. IfI have provided false information, I may be subject to a fine of not

more than $2,000 ($5,000 for subsequent offense) or imprisonment for not more than 2 years (5 years for subsequent offense), or both. Any false statement may constitute perjury.

18SIGN YOUR NAME IN BOX AT RIGHT.

DATE: ____________________________ / __________ / _________________

19IF YOU ARE UNABLE TO SIGN YOUR NAME, TWO WITNESSES TO YOUR MARK MUST SIGN HERE.

WITNESSSIGNATURE:

WITNESS SIGNATURE:

* Last 4 digits of the socialsecurity number required if no LA driver's license issued; social security number is intended to be used forvoter registration purposes only;

full # OPTIONAL. **OPTIONALLR-1 & 1M (REV. 7/15) R.S. 18:104; FORM #100