Download the form, print it, fill it and submit it to the state office to be apply for voting in the State of Arkansas.
Text Version of the Form
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PLEASE PRINT AND USE BLACK INK TO CO PLET E Rev. 6/ 11
Check all that apply : Office Use Only
____ This is a new registration.
____ This is a name change.
____ This is an address change.
____ This is a party change. Assigned ID
Mr. Last Name Jr. Sr. First Name Middle Name
Ms. II. III. IV.
Address Where You Live (See Section “C” Below) Apt. or Lot # City/Town County State Zip Code
2 (Rural addresses must draw map.)
Address Where You Receive Mail If Different From Above Apt. or Lot # City/Town County State Zip Code
Home & Work hone Numbers (Optional) arty Affiliation (Optional)
4 Date of Birth _________/_________/_________ 5 6
onth Day Year (H) (W)
7 E-mail Address (Optional) 8 Have you ever voted in a federal election in this State? Yes No
Signature of elector – lease sign full name or put mark.
ID Number – Check the applicable box and provide the appropriate number.
Arkansas Driverʼs license number ____________________________________
9 If you do not have a driverʼs license provide the last 4 digits of social
security number _____________________________
I have neither a driverʼs license nor social security number.
(A) Are you a citizen of the United States of America and an Arkansas resident?
Yes No The information I have provided is true to the best of my knowledge. I do not claim the right
(B) Will you be eighteen (18) years of age or older on or before election day? to vote in another county or state. If I have provided false information, I may be subject to
Yes No a fine of up to $10,000 and/or imprisonment of up to 10 years under state and federal laws.
(C) Are you presently adjudged mentally incompetent by a court of competent jurisdiction?
10 Yes No Date: _____________/_____________/_____________
(D) Have you ever been convicted of a felony without your sentence having been onth Day Year
discharged or pardoned? 11 If applicant is unable to sign his/ her name, provide name, address and
Yes No phone number of the person providing assistance:
If you checked No in response to either questions A or B, do not complete this form. Name ________________________ Address: ________________________
If you checked Yes in response to either questions C or D, do not complete this form. City :___________________ State:_____ hone# :_____________________
Please complete the sections below if : MAIL REGISTRANTS: PLEASE SEE SECTION D.
• You were previously registered in another county or state, or Agency Code (For Official Use Only)
• You wish to change the name or address on your current registration.
Mr. revious Last Name Jr. Sr. First Name Middle Name(s)
Ms. II. III. IV.
Date of Birth _________/_________/_________
onth Day Year
revious House Number and Street Name Apt.or Lot # City or Town State Zip Code
If you live in a rural area but do not have a house or street number, or if
you have no address, please show on the map where you live.
• Write in the names of the crossroads (or streets) nearest where you live. IDENTIFICATION REQUIRE ENTS
• Draw an “X” to show where you live.
C • Use a dot to show any schools, churches, stores or other landmarks near I PORTANT: If your voter registration application
where you live and write the name of the landmark. form is submitted by mail and you are registering for
the first time, and you do not have a valid Arkansas
driver’s license number or social security
Example NORTH D number, in order to avoid the additional identification
2 Store requirements upon voting for the first time you
# must submit with the mailed registration form: (a) a
t Woodchuck Road
u current and valid photo identification; or (b) a copy
• ublic School R of a current utility bill, bank statement, government
check, paycheck, or other government document
X that shows your name and address.
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To qualify to vote in the next election, you must apply to register to vote 30 days before the election.
If you mail this form, it must be postmarked by that date. You may also present it to a voter
registration agency representative by that date. If you miss the deadline you will not be registered
in time to vote in that election. Please don t delay. Make sure your vote counts.
If you are qualified and the information on your form is complete, you will be notified of your
voting precinct by your local County Clerk.
Fold form on middle perforation, remove plastic strip, seal at bottom, stamp and mail.
Call your local County Clerk
Arkansas Secretary of State
Elections Division – Voter Services
Contact your County Clerk if you have not received confirmation of this application
within two weeks.