North Carolina Voter Registration Application 05
DMV Agency Form
Qualifications to register to vote: Please note:
• You must be a U.S. citizen by birth or naturalization. The location where you received this
• You must register to vote only in the county in where you live. form will remain confidential and will
• You must be at least 18 years old by general election day OR you may preregister if you are at least 16 be used only for voter registration
years old and understand that you must be 18 years of age on or before election day to vote. purposes. If you choose not to register
• If convicted of a felony, you may register to vote only after you have completed your sentence, including to vote, your choice not to register will
probation or parole. After your sentence is completed, North Carolina automatically restores your also remain confidential.
citizenship rights including your right to vote. No special document is needed.
1 Your Qualifications to Vote
Check the appropriate box next to each question
Are you a citizen of the United States of America? Yes No
Note: If you checked “No” in response to this question, DO NOT submit this form. U.S. citizenship is required to vote.
Will you be at least 18 years of age on or before election day? Yes No
Are you at least 16 years of age and understand that you must be 18 years of age on or before election day to vote? Yes No
Note: If you checked “No” in response to both questions, DO NOT submit this form. You must be at least 18 years old to register to vote or at least 16 years old to preregister to vote.
2 Your Name 3 Your date of birth and identification information
Legal Last Name Date of Birth (MM/DD/YYYY) State or Country of Birth
CHANDRY 06/14/1988
Legal First Name NC Driver License or NC DMV ID Number Last Four Digits of Social Security Number
ALEXANDER 4829
Middle Name Suffix 000042607342
CHRISTIAN
4 Your Residential Address - where you physically live 5 Your Mailing Address (optional) – where you receive mail
DO NOT enter a P.O. Box or a mail drop location. If you do not receive mail where you live, please provide a mailing address.
Residential Address Mailing Address
152 AIREDALE TRL 5210 FALLS OF NEUSE RD
GARNER, NC, 27529-8890 APT B
RALEIGH, NC, USA, 276094838
County of Residence
JOHNSTON
6 Your Demographic Information and Party Affiliation (optional)
If you do not indicate a party affiliation, you will be registered as an unaffiliated voter.
Gender Race Ethnicity Party Affiliation
7 Your Previous Voter Registration Address (optional)
Please complete this section if you are currently registered to vote in another county or state.
Name Used in Last Registration
Address Where You Were Last Registered County or State of Last Registration
8 Your Contact Information (optional)
This information may be used to contact you concerning your voter registration. This information may be disclosed as a public record.
Phone Number
9 Your Attestation and Signature
I am declining voter registration services. I do not wish to register or preregister to vote at this time. I understand that
the fact I declined these services will remain confidential, except for administrative purposes related to voter
registration.
FRAUDULENTLY OR FALSELY COMPLETING THIS FORM IS A CLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES.
X 2020.08.12 17.00.32
Signature Date
NCSBOE 2018.03
