New York State Voter Registration Form

Instructions Send or deliver this form Verifying your identity

Fill out the form on page 2 of this PDF We’ll try to check your identity before
With this form, you register to vote in document and mail it to your county’s Election Day, through the DMV number
elections in New York State. You can also address from the list of addresses below, (driver’s license number or non-driver
use this form to: or take the form to the office of your ID number), or the last four digits of
• change the name or address County Board of Elections. your social security number, which
on your voter registration you’ll fill in below.
Mail or deliver this form at least 25 days
• become a member of before the election you want to vote If you do not have a DMV or social
a political party
in. Your county will notify you that you are security number, you may use a valid
• change your party membership
registered to vote. photo ID, a current utility bill, bank
statement, paycheck, government check
To register you must: Questions? or some other government document that
• be a US citizen; Call your County Board of Elections shows your name and address. You may
• be 18 years old by the end of this year; listed on the back of this form or include a copy of one of those types of ID
• not be in prison or on parole 1-800-FOR-VOTE(TDD/TTY Dial 711) when you mail this form.
for a felony conviction; If we are unable to verify your identity
Find answers or tools on our website
• not claim the right to vote elsewhere. www.elections.state.ny.us 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

(Optional) Register to donate your organs and tissues

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 complete the form below and mail it in with your Voter
Registration Form.
You will receive a confirmation letter from DOH, which will also provide you an opportunity to limit your donation.

Last name By signing below,

you certify that you are:
First name
• 18 years of age or older;
Middle Initial Suffix • consenting to donate all of your organs and
tissues for transplantation, research, or both;
• authorizing the Board of Elections to provide
Address
your name and identifying information to
DOH for enrollment in the Registry;
Apt. Number Zip code • and authorizing DOH to allow access to this
information to federally regulated organ procure-
City ment organizations and NYS-licensed tissue
and eye banks and hospitals upon your death.
Birth date
M M / D D / Y Y Y Y Sex M F

Eye color Height Ft. In.

Sign Date
New York State Voter Registration Form (See instructions on page 1)
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.

Are you a citizen of the U.S.? Yes No For board use only
1
If you answer No, you cannot register to vote.
Qualifications
Will you be 18 years of age or
2 older on or before election day? Yes No
If you answer No, you cannot register to vote unless you will be 18 by the end of the year.

Last name Suffix

Your name 3
First name Middle Initial

4 Birth date
M M / D D / Y Y Y Y 5 Sex M F
More information
6 Telephone (optional)
– –

Address (not P.O. Box)

Apt. Number Zip code

The address 7
where you live City/Town/Village

New York State County

Address or P.O. Box

The address where
you receive mail 8 P.O. Box Zip code
Skip if same as above
City/Town/Village

Voting history 9 Have you voted before? Yes No 10 What year?

Voting information Your name was

that has changed 11 Your address was
Skip if this has not changed or
you have not voted before Your previous state or New York State County was

Identification New York State DMV number

You must make 1 selection
12 x x x – x x –
Last four digits of your Social Security number
For questions, please refer to
Verifying your identity above. I do not have a New York State driver’s license or a Social Security number.

Political party Democratic party Affidavit: I swear or affirm that

You must make 1 selection Republican party • I am a citizen of the United States.
• I will have lived in the county, city or village
Independence party for at least 30 days before the election.
To vote in a primary election,
you must be enrolled in one 13 Conservative party • I meet all requirements to register
of these listed parties — to vote in New York State.
except the Independence Party, Working Families party • This is my signature or mark in the box below.
which permits non-enrolled voters • The above information is true, I understand that
to participate in certain primary
Other 15 if it is not true, I can be convicted and fined up
elections. I do not wish to enroll in a party to $5,000 and/or jailed for up to four years.

I need to apply for Sign

an Absentee ballot (optional).
Optional questions 14
I would like to be an
Election Day worker (optional). Date
Your address
Place
First-class
stamp
here

Your County Board of Elections address

New York City Chenango Franklin Lewis Oneida Putnam Schuyler Ulster
Executive Offices 5 Court St. 355 West Main St. 7660 N. State St. Union Station 25 Old Route 6 County Office Bldg. 284 Wall St.
32 Broadway, 7th Fl. Norwich, NY 13815 Ste. 161 Lowville, NY 13367 321 Main St. Carmel, NY 10512 105 9th St., Unit 13 Kingston, NY 12401
New York, NY (607) 337-1760 Malone, NY 12953 (315) 376-5329 3rd Fl. (845) 278-6970 Watkins Glen, NY (845) 334-5470
10004 (518) 481-1663 Utica, NY 13501 14891
Clinton Livingston (315) 798-5765 Rensselaer (607) 535-8195 Warren
(212) 487-5300
Cnty Government Ctr. Fulton County Govt. Ctr. Ned Pattison Cnty. Municipal Ctr.
137 Margaret St. 2714 St. Hwy 29 6 Court St. Onondaga Government Ctr. Seneca 1340 St. Rte. 9
Albany Ste. 104 Ste. 1 Room 104 Civic Ctr. 1600 Seventh Ave. One DiPronio Dr. Lake George, NY
32 North Russell Road Plattsburgh, NY 12901 Johnstown, NY 12095 Geneseo, NY 14454 421 Montgomery St., Troy, NY 12180 Waterloo, NY 13165 12845
Albany, NY 12206 (518) 565-4740 (518) 736-5526 (585) 243-7090 15th Fl. (518) 270-2990 (315) 539-1760 (518) 761-6456
(518) 487-5060 Syracuse, NY 13202
Columbia Genesee Madison (315) 435-3312 Rockland Steuben Washington
Allegany 401 State St. County Building #1 County Office Bldg. 11 New Hempstead Rd. 3 E. Pulteney Sq. 383 Broadway
6 Schuyler St. Hudson, NY 12534 15 Main St. N. Court St. Ontario New City, NY 10956 Bath, NY 14810 Fort Edward, NY
Belmont, NY 14813 (518) 828-3115 PO Box 284 PO Box 666 74 Ontario St. (845) 638-5172 (607) 664-2260 12828
(585) 268-9294 Batavia, NY 14021 Wampsville, NY 13163 Canandaigua, NY (518) 746-2180
Cortland (585) 344-2550 (315) 366-2231 14424 St. Lawrence Suffolk
Broome 112 River St. (585) 396-4005 48 Court St. PO Box 700 Wayne
Government Plaza Room 103 Greene Monroe Canton, NY 13617 Yaphank Ave. 157 Montezuma St. Ext.
44 Hawley St. Cortland, NY 13045 411 Main St. 39 Main St. W. Orange (315) 379-2202 Yaphank, NY 11980 PO Box 636
PO Box 1766 (607) 753-5032 Ste. 437 Rochester, NY 14614 25 Court Lane (631) 852-4500 Lyons, NY 14489
Binghamton, NY Catskill, NY 12414 (585) 753-1550 PO Box 30 Saratoga (315) 946-7400
13902 Delaware (518) 719-3550 Goshen, NY 10924 50 W. High St. Sullivan
(607) 778-2172 3 Gallant Ave. Montgomery (845) 291-2444 Ballston Spa, NY Gov’t. Ctr. Westchester
Delhi, NY 13753 Hamilton Old Courthouse 12020 100 North St. 25 Quarropas St.
Cattaraugus (607) 746-2315 Rte. 8 9 Park St. Orleans (518) 885-2249 PO Box 5012 White Plains, NY
302 Court St. PO Box 175 PO Box 1500 14012 State Rte. 31 Monticello, NY 12701 10601
Little Valley, NY 14755 Dutchess Lake Pleasant, NY Fonda, NY 12068 Albion, NY 14411 Schenectady (845) 807-0400 (914) 995-5700
(716) 938-2400 47 Cannon St. 12108 (518) 853-8180 (585) 589-3274 388 Broadway, Ste. E
Poughkeepsie, NY (518) 548-4684 Schenectady, NY Tioga Wyoming
Cayuga 12601 Nassau Oswego 12305 County Office Bldg. 4 Perry Ave.
10 Court St. (845) 486-2473 Herkimer 240 Old Country Rd. 185 E. Seneca St. (518) 377-2469 56 Main St. Warsaw, NY 14569
Auburn, NY 13021 109 Mary St. 5th Fl. Box 9 Owego, NY 13827 (585) 786-8931
(315) 253-1285 Erie Ste. 1306 Mineola, NY 11501 Oswego, NY 13126 Schoharie (607) 687-8261
134 W. Eagle St. Herkimer, NY 13350 (516) 571-2411 (315) 349-8350 County Office Bldg. Yates
Chautauqua Buffalo, NY 14202 (315) 867-1102 284 Main St. Tompkins Ste. 1124
7 North Erie St. (716) 858-8891 Niagara Otsego PO Box 99 Court House Annex 417 Liberty St.
Mayville, NY 14757 Jefferson 111 Main St. Ste. 2 Schoharie, NY 12157 128 E. Buffalo St. Penn Yan, NY 14527
(716) 753-4580 Essex 175 Arsenal St. Ste. 100 140 County Hwy. 33W (518) 295-8388 Ithaca, NY 14850 (315) 536-5135
7551 Court St. Watertown, NY 13601 Lock port, NY 14094 Cooperstown, NY (607) 274-5522
Chemung PO Box 217 (315) 785-3027 (716) 438-4040 13326
378 South Main St. Elizabethtown, NY (607) 547-4247
PO Box 588 12932
Elmira, NY 14902 (518) 873-3474
(607) 737-5475