a. The Secretary of State shall cause to be prepared and shall provide to each county commissioner of registration forms of size and weight suitable for mailing, which shall require the information required by R.S.19:31-3 in substantially the following form:
VOTER REGISTRATION APPLICATION
Print clearly in ink. Use ballpoint pen or marker.
(1) This form is being used as:
[ ] New registration
[ ] Address change
[ ] Name change
(2) Name:.....................................................
Last First Middle
(3) Are you a citizen of the United States of America? [ ] Yes [ ] No
(4) Will you be 18 years of age on or before election day? [ ] Yes [ ] No
If you checked 'No' in response to either of these questions, do not complete this form.
(5) Street Address where you live:
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Street Address Apt. No.
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(6) City or Town County Zip Code
(7) Address Where You Receive Your Mail (if different from above):
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(8) Date of Birth:
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Month Day Year
(9)
(a) Telephone Number (optional)......................
(b) E-Mail Address (optional).....................
(10) Name and address of Your Last Voter Registration
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.............................................
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(11) If you are registering by mail to vote and will be voting for the first time in your current county of residence, please provide one of the following:
(a) your New Jersey driver's license number:................................
(b) the last four digits of your Social Security Number....................
OR submit with this form a copy of any one of the following documents: a current and valid photo identification card; a current utility bill, bank statement, government check, pay check or any other government or other identifying document that shows your name and current address. If you do not provide either your New Jersey driver's license number or the last four digits of your Social Security Number, or enclose a copy of one of the documents listed above, you will be asked for identification when voting for the first time, unless you are exempt from doing so under federal or State law.
(12) Do you wish to declare a political party affiliation? (Optional):
[ ] YES. Name of Party:
[ ] NO. I do not wish to declare a political party affiliation at this time.
(13) [ ] I wish to receive a Mail-in Ballot for all future elections, until I request otherwise in writing.
(14) Declaration - I swear or affirm that:
I am a U.S. citizen.
I live at the above address.
I will be at least 18 years old on or before the day of the next election.
I am not serving a sentence of incarceration due to a conviction for an indictable offense under any federal or State laws.
I UNDERSTAND THAT ANY FALSE OR FRAUDULENT REGISTRATION MAY SUBJECT ME TO A FINE OF UP TO $15,000, IMPRISONMENT UP TO FIVE YEARS, OR BOTH PURSUANT TO R.S.19:34-1.
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Signature or mark of the registrant Date
(15) If applicant is unable to complete this form, print the name and address of individual who completed this form.
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Name
....................................
Address
In addition, the form may include notice to the applicant of information and options relating to the registration and voting process, including but not limited to notice of qualifications required of a registered voter; notice of the final day by which a person must be registered to be eligible to vote in an election; notice of the effect of a failure to provide required identification information; a place at which the applicant may indicate availability for service as a member of the district board of elections; a place at which the applicant may indicate whether he or she requires a polling place which is accessible to individuals with disabilities and the elderly or whether he or she is legally blind; a place at which the applicant may indicate a desire to receive additional information concerning voting by mail; and if the application indicates a political party affiliation, the voter is permitted to vote in the primary election of a political party other than the political party in which the voter was affiliated previously only if the voter registration form with the change of political party affiliation is filed prior to the 50th day next preceding the primary election. The form may also include a space for the voter registration agency to record whether the applicant registered in person, by mail or by other means.