Ill. Admin. Code tit. 26, § 216.EXHIBIT A – Voter Registration Application-Illinois

ILLINOIS VOTER REGISTRATION APPLICATION

FOR U.S. CITIZENS ONLY	YOU CAN USE THIS FORM TO:
(If you are not a citizen, do not continue)		apply to register to vote in the State of Illinois
TO REGISTER YOU MUST:		change your address on your voter registration card
	be a United States citizen		change your name (change due to marriage, etc.)
	be at least 18 years old on or before the next election
	live in your election precinct at least 30 days before the next election	TO COMPLETE THIS FORM:
		Box 1 – If you do not have a middle name, print "none"
	not be convicted and in jail		Box 3: – If you have never registered before, print “none”. If you do not remember your former address, print "unsure". If you have not changed your name, print "same".
	not claim the right to vote anywhere else

DEADLINE INFORMATION:
	Mail or deliver this form no later than 29 days before the next election.		Box 8 – Read, date and personally sign your name or
		make your mark in the box.
	If you do not receive a Notice within 2 weeks of mailing or delivering this form, call the County Clerk or Board of Election Commissioners named on the front of this card.	IF YOU HAVE NO STREET ADDRESS, describe your home: list the name of subdivisions; cross streets; roads; landmarks, mileage and/or neighbor's names.


IMPORTANT INFORMATION:
	if you register by mail, the first time you vote must be in person	N

	W			E
	if you register at a public service agency, any information regarding the agency which assisted you will remain confidential as will any decision not to register

		S

FOLD LINE

PRINT CLEARLY OR TYPE IN BLACK OR BLUE INK

Office Use

1. Last NAME

First Name

Middle Name or Initial

Suffix (Circle One)

JR. SR. II III IV

2. Address where you live (do not give P.O. address) House No. Street Name

City/Village/Town

Township

Apt. No./P.O. Box

County

Zip Code

3. Former Registration Address: (include City and State)

County

Former Name: (if changed)

4. Date of Birth:

5. Sex (Circle One)

6. Telephone Number (optional)

7. Full Social Security No. Or last 4 digits only

Month Day Year

M F

Voter Affidavit – Read all statements and sign within

This is my signature or mark in the space below.

the box to the right. I swear or affirm that

I am a citizen of the United States:

I will be at least 18 years old on or before the next election;

I will have lived in the State of Illinois and in my election precinct 30 days as of the date of the next election.

All of the above information is true. I understand that if it is not true, I can be convicted of perjury and fined up to $5,000 and/or jailed for 2 to 5 years.

Date:

If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.

Name

Full Address

Telephone No.

FOLD ON DOTED LINES, PEEL OFF TAPE, SEAL AND MAIL

*Mandated Oct. 1996

YOUR ADDRESS

back of SBE No. R-19

PUT

FIRST

CLASS

STAMP

HERE

MAIL TO:

CHANGE OF ADDRESS

PCT

WARD

CODE

ADDRESS

CITY

ZIP

COUNTY

DATE

CLERK

SUSPENSION, CANCELLATION AND REINSTATEMENT

DATE

EXPLAIN

CLERK

DATE

EXPLAIN

CLERK

To Election Judges:

Voting Record

95 96 97 98 99 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

For Primary, mark

Primary

D for Democrat

General

R for Republican

NonPartisan

for all other

Special

elections, markV

*Mandated: Oct. 1996

SBE No. R-19A

Office Use

1. Last Name First Name Middle Name or Initial

Suffix (Circle One) JR. SR. II III IV

2. Address where you live (do not give P.O. address) House No. Street Name

City/Village/Town

Township

Apt. No./P.O. Box

County

Zip Code

3. Former Registration Address: (include City and State)

County

Former Name: (if changed)

4. Date of Birth: Month Day Year

5. Sex (Circle One) M F

6. Telephone Number (optional)

7. Full Social Security No. Or last 4 digits only

Voter Affidavit – Read all statements and sign within

This is my signature or mark in the space below.

the box to the right. I swear or affirm that

I am a citizen of the United States;

I will be at least 18 years old on or before the next

election;

I will have lived in the State of Illinois and in my

election precinct 30 days as of the date of the next

election.

All of the above information is true. I understand

that if it is not true, I can be convicted of perjury and

fined up to $5,000 and/or jailed for 2 to 5 years.

Date:

If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.

Name

Full Address

Telephone No.

back of SBE No. R-19A

CHANGE OF ADDRESS

PCT

WARD

CODE

ADDRESS

CITY

ZIP

COUNTY

DATE

CLERK

SUSPENSION, CANCELLATION AND REINSTATEMENT

DATE

EXPLAIN

CLERK

DATE

EXPLAIN

CLERK

To Election Judges:

Voting Record

95 96 97 98 99 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

For Primary, mark

Primary

D for Democrat

General

R for Republican

NonPartisan

for all other

Special

elections, markV

STOCK 110 lb. CARD OR COMPARABLE STOCK

COLOR WHITE

SIZE 5" x 8"

TYPEFACE SIMPLE SANS SERIF, 7 AND 8 PT.

AS MANDATED BY PUBLIC LAW 103-31, THE FOLLOWING INFORMATION MUST BE PRINTED IN THE SAME TYPEFACE (ONLY THIS MATERIAL, WILL BE PRINTED IN THE 8 PT. TYPEFACE): THE BULLETED INFORMATION IN THE INSTRUCTIONS SECTION ENTITLED "TO REGISTER YOU MUST" AND "IMPORTANT INFORMATION" AND THE INFORMATION ON THE REGISTRATION FORM #8 "VOTER AFFIDAVIT"

SEAL PULL OFF ADHESIVE TAPE

(bottom edge)