Texas Voter Registration Applicatior Pred ty the Of fhe Secretary of Sate VRITAOISE Please complete sections by printing LEGIBLY, Ifyou have any questions about how to fil out this application, please call the Harris County Voter Registrars Office at 713-274-VOTE (8683) or the Secretary of State's Office toll free at “abo 252.V0TE (8683) ‘TDD 1-800-735-2989, www.sos.state.tx.us. These Questions Must Be Completed Before Proceeding (Check one) [Ly New Application [E17 Change of Address, Name, [~] _ Request for a Replacement Card or Other Information en? OO Yes 1 no Are you a United States Ci Will you be 18 years of age on or before election day? OO ves [no Are you interested in serving as an election worker? OO ves OO wo Last Name inciude Suftxirany [First Name Middle Name [Former Name (t any) (Jr, Sr, IM) (ifany) Residence Address: Street Address and Apartment Number. if | City TEXAS none, describe where you live, (De rot include P.O. Box, Rural Rt oF Business Aasre3s) County Zip Code Mailing Address: Street Address and Apartment Number. City State (if mail cannot be delivered to your residence address.) Zip Code City and County of Former Residence in Texas oo/oo! oe. (COO0Uo-0 ‘Texas Driver's License No. or Texas Personal ifno Texas Driver's License or Personal Identification, LD. No. (issued by the Department of Public Safety) give last 4 digits of your Social Security Number L] [ [ XX-xX- [ [ | have not been issued a Texas Driver's License/Personal Identification Number or Social Security Number. lunderstand 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 180 days, a fine up to $2,000, or both. Please read all three statements to affirm before signing. + 1am a resident of this county and a U.S. citizen; + Ihave not been finally convicted of a felony, or ifa felon, I have completed all of my punishment including any term of incarceration, parole, supervision, period of probation, or | have been pardoned; and a Date of Birth: (mm/ddlyyyy) F ‘Gender (Optional) [fs] Telephone Number (Optional) + Ihave 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. pate / / int or Printed Name of Applicant if Signed by Witness and Date.