INSTRUCTIONS FOR FILLING OUT THIS FORM (PLEASE READ CAREFULLY)Box 3.

Box 8. Prior Registration: If you were registered before, fill in the name used onyour previous registration in Box 8a and address, county and year ofprevious registration in Box 8b.

Box 10.

Box 11. Registration Declaration: You must be a citizen of the United States toregister to vote in the Commonwealth of Pennsylvania. Please read theregistration declaration carefully. You must sign and print your name anddate the application.

Box 12. If you were assigned a Voter Identification Number, which appears onyour Voter Identification Card, place that Identification Number, if available,here. If you are applying to register to vote for the first time, leave this box blank.

Box 4. 4a Address of Residence:

Box 4c In Box 4c fill in the name of the municipality (city, borough or township) and county where you live. Use the map in the box below if you cannot otherwise identify your address.

Fill in your complete address of residence.P.O. boxes may not be used here unless there is no physical address.Print street address, city and zip code. (If the residence is only a portion ofthe house, include the location or number of the room, apartment or floorwhich is occupied.) 4b Although providing your telephone number isoptional, it is a quick and easy way for your county to contact you if thereis missing information on your registration form.

If your address of residence listed in Box 4a has no street number or streetname (for example, Schoolhouse Road or RR2 Box 3) use the box aboveto draw a map of where you live. Include landmarks and roads.

NORTH

SOUTH

WEST EAST

12

10

8b

6

4c

4a

a3

b3

2

1

5

4b

7 8a

9

M

F

11

PENNSYLVANIA VOTER REGISTRATION APPLICATION

Are you a citizen of the United States of America? Yes NoWill you be 18 years of age on or before election day? Yes No

New Registration Change of Name Change of Address Change of PartyI am a Federal or State employee and wish to retain my voting residence in the county where I last resided.

} If you checked “No” in response to either of these questions, do not complete this form.

Last Name

Place PA Driver’s License (DL) # hereif you have one:

If no PA DL #, Place SS# (last 4 digits) here:

First Name Middle Name/Initial

Address of residence, include street and city (Use map above if no street number or name) (If only P.O. box, see above) Apt # State Zip Code Telephone Number (Optional)

PA ( )

Jr Sr II III IV(circle if applicable)

Municipality where you live County where you live Mailing Address (if different than address of residence) City State Zip Code

Date of Birth Race (Optional) Name on previous registration

/ /Address of previous registration (include street and city)

County of previous registration Year of previous registration

Name and signature of person who assisted in the completion of this application

Address

In which party do you wish to register?

Other

Place signature with full name (or mark) below.(Please see Penalty for Falsifying Declaration.)

Print Your Name Below Date:

/ /

X

Voter Identification Number (If available - not necessary if you are registering to vote for the first time or if you do not know your number.)

13 Do you require assistancewhen voting? Yes No

Reason for assistance:

Box 13. If you require assistance when voting, you must check the box and provide the reason.

REGISTERANDVOTE

PENNSYLVANIA VOTER REGISTRATIONMAIL APPLICATION

To Register You Must:Be a citizen of the United States for at least one month before the next election; Be a resident of Pennsylvania and your election district for at least 30 days before the next election; and Be at least 18 years of age on the day of the next election.

GENERAL INSTRUCTIONSwww.VotesPA.com

Name of Assistant: If the applicant is unable to complete or sign the application, the person who assisted the applicant must provide his or her name, address and signature.

I DO NOT have a PA Driver’s License or Social Security Number.

You must register with a party if you want to take part in that party’s primary.

I HEREBY DECLARE THAT:(1) On the day of the next election I will have been a United States citizen for at least one month. I will be at least 18 years of age, and I will have resided in Pennsylvania and in my election district for at least 30 days;

(2) I am legally qualified to vote.

AND I HEREBY AFFIRM THAT the information I have provided in this registration declaration is true. I understand that this registration declaration will be accepted for all purposes as the equivalent of an affidavit; and if the registration contains a materially false statement, I will be subject to penalties for perjury.

1. Please provide all information on the application as required. Read all instructions carefully before you fill out the application.2. If you are currently registered, you do not need to re-register unless you have moved or changed your name since you last registered.3. In order to vote at the next election, this application must be received by your county voter registration office no later than 30 days before the

election, or postmarked no later than the thirtieth day before the election. Military electors may apply at any time. For more information on military and overseas electors, see www.fvap.gov.

4. Write the mailing address for your county voter registration office on the reverse side of this application and place the proper postage in the designated area. Addresses for all Pennsylvania counties are listed on the back of this form.

5. You are not registered to vote until your application has been processed and accepted by the county voter registration office. If accepted, the county voter registration office will send you, via nonforwardable mail, a Voter Identification Card. If you do not receive a Voter Identification Card within 14 days of the date you submit this application, contact your county voter registration office.

6. If you decline to register to vote, your decision will remain confidential. If you register to vote, the office at which you register will remain confidential and be used for voter registration purposes only.

7. Do not use staples or duct tape.8. Print and sign clearly in blue or black pen.

PENALTY FOR FALSIFYING REGISTRATION DECLARATIONWARNING: If a person signs an official registration application knowing a statement declared in the application to be false, makes a false registration, or furnishes false information, the person commits perjury. Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven years, or a fine not exceeding $15,000, or both, at the discretion of the court. Submitting an application containing false information may also subject a person to other penalties, including loss of the right of suffrage, under state or federal law.

Democratic No affi liationRepublican

3b Pennsylvania Driver�’s License (DL), PennDOT ID # OR Social Security Number: You must supply a PA Driver�’s License Number or PennDOT ID # if you have one. If you do not have a PA Driver�’s License Number or PennDOT ID #, you must supply the last four digits of your Social Security Number. If you do not have a Social Security Number, please check the box to the right of 3b.

5/11

ADAMS COUNTY117 BALTIMORE ST RM 106 GETTYSBURG PA 17325(717) 337-9832

CHESTER COUNTY601 WESTTOWN RD STE 150PO BOX 2747WEST CHESTER PA 19380-0990(610) 344-6410

FULTON COUNTY116 W MARKET ST STE 203MCCONNELLSBURG PA 17233(717) 485-3691

MERCER COUNTY 5 COURTHOUSEMERCER PA 16137-1227(724) 662-7542

SULLIVAN COUNTY245 MUNCY ST PO BOX 157LAPORTE PA 18626(570) 946-5201

ALLEGHENY COUNTY542 FORBES AVE STE 609PITTSBURGH PA 15219-2913(412) 350-4500

CLARION COUNTY330 MAIN ST RM 103 CLARION PA 16214(814) 226-4000 EXT 2205

GREENE COUNTY93 E HIGH ST RM 102WAYNESBURG PA 15370(724) 852-5230

MIFFLIN COUNTY20 N WAYNE STLEWISTOWN PA 17044(717) 248-6571

SUSQUEHANNA COUNTYPO BOX 218 105 MAPLE STMONTROSE PA 18801(570) 278-4600 EXT 220

ARMSTRONG COUNTYADMINISTRATION BUILDING 450 E MARKET ST SUITE 207 KITTANNING PA 16201(724) 548-3222

CLEARFIELD COUNTY212 E LOCUST ST STE 106CLEARFIELD PA 16830(814) 765-2641

HUNTINGDON COUNTY233 PENN ST COURTHOUSEHUNTINGDON PA 16652-1486(814) 643-3091 EXT 205

MONROE COUNTYONE QUARKER PLAZA RM 105STROUDSBURG PA 18360(570) 517-3165

TIOGA COUNTY118 MAIN ST WELLSBORO PA 16901(570) 723-8230

BEAVER COUNTY810 THIRD STBEAVER PA 15009(724) 770-4440

CLINTON COUNTY232 E MAIN ST GARDEN BLDG 3RD FLLOCK HAVEN PA 17745-1385(570) 893-4019

INDIANA COUNTY825 PHILADELPHIA STINDIANA PA 15701-3934(724) 465-3852

MONTGOMERY COUNTYVOTER REGISTRATION PO BOX 311NORRISTOWN PA 19404-0311(610) 278-3280

UNION COUNTY155 N 15TH STLEWISBURG PA 17837-8822(570) 524-8681

BEDFORD COUNTY200 S JULIANA ST 3RD FLBEDFORD PA 15522(814) 623-4807

COLUMBIA COUNTYPO BOX 380BLOOMSBURG PA 17815-0380(570) 389-5640

JEFFERSON COUNTY155 MAIN ST JEFFERSON PLACEBROOKVILLE PA 15825-1269(814) 849-1605

MONTOUR COUNTY29 MILL STDANVILLE PA 17821(570) 271-3000

VENANGO COUNTY1174 ELK ST PO BOX 831FRANKLIN PA 16323-0831(814)432-9514

BERKS COUNTY633 COURT STREADING PA 19601(610) 478-6490

CRAWFORD COUNTY903 DIAMOND PARKMEADVILLE PA 16335(814) 333-7306

JUNIATA COUNTY1 NORTH MAIN ST PO BOX 68MIFFLINTOWN PA 17059(717) 436-7706

NORTHAMPTON COUNTY670 WOLF AVEEASTON PA 18042(610) 559-3055

WARREN COUNTY204 4TH AVEWARREN PA 16365(814) 728-3406

BLAIR COUNTY423 ALLEGHENY ST STE 043HOLLIDAYSBURG PA 16648-2022(814) 693-3150

CUMBERLAND COUNTY310 ALLEN RD STE 101CARLISLE PA 17013-3044(717) 240-6385

LACKAWANNA COUNTY2400 STAFFORD AVE PO BOX 4524SCRANTON PA 18505(570) 963-6737

NORTHUMBERLAND COUNTY320 N 2ND ST STE 1 SUNBURY PA 17801(570) 988-4208

WASHINGTON COUNTY100 W BEAU ST RM 206WASHINGTON PA 15301(724) 228-6750

BRADFORD COUNTY6 COURT ST STE 2TOWANDA PA 18848(570) 265-1717

DAUPHIN COUNTYPO BOX 1295HARRISBURG PA 17108-1295(717) 780-6360

LANCASTER COUNTY150 N QUEEN ST STE 117LANCASTER PA 17603-3562(717) 299-8293

PERRY COUNTYPO BOX 37NEWBLOOMFIELD PA 17068-0037(717) 582-2131 EXT 4110

WAYNE COUNTY925 COURT STHONESDALE PA 18431(570) 253-5978

BUCKS COUNTY55 E COURT STDOYLESTOWN PA 18901-4318(215) 348-6163

DELAWARE COUNTYGOVT CENTER BLDG 201 W FRONT STMEDIA PA 19063-2728(610) 891-4659

LAWRENCE COUNTY430 COURT STNEW CASTLE PA 16101(724) 656-2161

PHILADELPHIA COUNTY520 N DELAWARE AVE 5TH FLPHILADELPHIA PA 19123-4295(215) 686-1591

WESTMORELAND COUNTY2 N MAIN ST STE 109GREENSBURG PA 15601(724) 830-3150

BUTLER COUNTYPO BOX 1208 BUTLER PA 16003(724) 284-5308

ELK COUNTY300 CENTER ST PO BOX 448RIDGWAY PA 15853-0448(814) 776-5337

LEBANON COUNTY400 S 8TH ST RM 209 MUNICIPAL BLDGLEBANON PA 17042(717) 228-4428

PIKE COUNTY506 BROAD STMILFORD PA 18337(570) 296-3427

WYOMING COUNTY1 COURTHOUSE SQTUNKHANNOCK PA 18657(570) 996-2226

CAMBRIA COUNTY200 S CENTER STEBENSBURG PA 15931(814) 472-1464

ERIE COUNTY140 W 6 ST RM 112ERIE PA 16501(814) 451-6276

LEHIGH COUNTY17 S 7TH STALLENTOWN PA 18101-2401(610) 782-3194

POTTER COUNTY1 N MAIN ST STE 204COUDERSPORT PA 16915(814) 274-8487

YORK COUNTY28 EAST MARKET STYORK PA 17401-1579(717) 771-9604

CAMERON COUNTY20 E FIFTH STEMPORIUM PA 15834-1469(814) 486-9322

FAYETTE COUNTY22 E MAIN ST PUBLIC SERVICE BLDGUNIONTOWN PA 15401(724) 430-1289

LUZERNE COUNTY20 N PENNSYLVANIA AVE STE 207WILKES-BARRE PA 18701-3505(570) 825-1715

SCHUYLKILL COUNTY420 N CENTRE STPOTTSVILLE PA 17901(570) 628-1467

CARBON COUNTY76 SUSQUEHANNA ST PO BOX 170JIM THORPE PA 18229-0170(570) 325-4801

FOREST COUNTY526 ELM ST BOX 3TIONESTA PA 16353(814) 755-3537

LYCOMING COUNTY48 W THIRD STWILLIAMSPORT PA 17701-9536(570) 327-2267

SNYDER COUNTYPO BOX 217MIDDLEBURG PA 17842-0217(570) 837-4207

CENTRE COUNTY420 HOLMES STWILLOWBANK OFFICE BLDG BELLEFONTE PA 16823-1486(814) 355-6703

FRANKLIN COUNTY157 LINCOLN WAY EASTCHAMBERSBURG PA 17201-2211(717) 261-3886

MCKEAN COUNTY500 W MAIN ST COURTHOUSESMETHPORT PA 16749(814) 887-3203

SOMERSET COUNTY300 N CENTER AVE STE 340SOMERSET PA 15501(814) 445-1549

Email Address

There are identi cation requirements when voting. For details and a complete list of acceptable forms of identi cation please visitwww.votespa.com, call your County Board of Elections or 1-877-VOTESPA.