Please click on the “Print Application” button below after verifying your data.
Sign the form;
Insert in an envelope addressed to the county (the address is at the top of the form);
Place a first class stamp on the envelope; and
Mail.
For added security please close this browser window after printing.
Your County Voter Registrar/Elections Administrator must receive this printed application for you to become a registered voter. Filling in this information online does not register you.
Texas Voter Registration Application
VR17.11EI3
For Official Use Only
Please mail this application to:
REGISTRAR OF VOTERS
1
Application Type:
Are you a United States Citizen? .....................................................................................
Will you be 18 years of age on or before election day?.................................................... If you checked ‘no’ in response to either of the above, do not complete this form.
Are you interested in serving as an election worker? ....................................................... No
Continue below to complete application.
2
Last Name: Include Suffix if any
(Jr, Sr, III)
First Name
Middle Name(If Any)
Former Name (If Any)
3
Residence Address:Street Address and Apartment Number.
If none, describe where you live. (Do not include P.O. Box, Rural Rt. or Business Address)
City
County
State
Zip Code
4
Mailing Address:Street Address and Apartment Number (If mail cannot be delivered to your residence address.)
City
State
Zip Code
5
City and County of Former Residence in Texas
6
Date of Birth: (mm/dd/yyyy)
//
7
Gender(Optional)
8
Telephone Number, Include Area Code(Optional)
9
Texas Driver's License No. or Texas Personal I.D. No. (Issued by the Department of Public Safety)
If no Texas Driver's License or Personal Identification, give last 4 digits of your Social Security Number
10
I understand that giving false information to procure a voter registration is perjury, and a crime under state and federal law. Conviction of this crime may result in imprisonment up to one year in jail, a fine up to $4,000, or both. Please read all three statements to affirm before signing.
I am a resident of this county and a U.S. Citizen;
I have not been finally convicted of a felony, or if a felon, I have completed all of my punishment including any term of incarceration, parole, supervision, period of probation, or I have been pardoned; and
I have not been determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially mentally incapacitated without the right to vote.
X
_______ / _______ / _______
Date
Signature of Applicant or Agent and Relationship to Applicant or Printed Name of Applicant if Signed by Witness and Date.