Voter Registration Instructions You…

                                 Voter Registration Instructions
You can use this application to:                 * Identification number requirements
·   register to vote in Kansas, change your name or your address Enter your current Kansas driver's license number or the last four
    on your registration, affiliate with a political party, or change digits of your Social Security number. If you do not have either
    your party affiliation.                                           number, darken the appropriate circle. The last four digits of your
                                                                      Social Security number will be used for administrative purposes
To register to vote you must:                                         only and will not be disclosed to the public (KSA 25-2309).
· be a U. S. citizen and a resident of the State of Kansas.
· have reached the age of 18 years before the next statewide Notice to mail-in registrants
    general election.
                                                                      If you mail your application and are registering to vote for the first
· have received final discharge from imprisonment, parole, or time in this county, and do not provide an identification number as
    conditional release if convicted of a felony.                     requested above, then you must complete one of the following
· have abandoned your former residence and/or name.                   options.

How to register to vote                                                                        a) Send a copy of a current, valid photo ID along with your
·    Return your completed application to your county. Addresses                                  application, or
     are on the back of this application. Your county election officer                         b) Send a copy of a current utility bill, bank statement, government
     will mail you a notice when your application has been processed.                            check, paycheck, or other government document that shows
·    Postmark this application by the 15th day before an election                                 your name and address.
     in order to be eligible to vote in that election.
·    If you decline to register to vote, that fact will remain confiden-                       If these requirements are not met, you must provide identification
     tial and will be used for voter registration purposes only. If you                        the first time you vote in the county.
     do register to vote, the office where you apply will be kept                             For further information contact the Office of the Secretary of State,
     confidential and will be used for voter registration purposes only.                      1-800-262-VOTE (8683) V/TTY. This form is available at
·    If this form is incomplete, it may be rejected.                                          www.kssos.org.
                                                         Print in blue or black ink, fold on center line, seal and return.



                                      Kansas Voter Registration Application
Qualifications If you marked no in response to either of these questions, do not complete this form.
Are you a citizen of the United States of America?                  YES        NO           Will you be 18 years of age on or before Election Day?                    YES           NO
Personal Information              please print


Name                   Last                                 First                         Middle                Jr. Sr. II III IV            Daytime phone number (if available)


Residence address (include apt. or space number)                                City                            County                       Zip            Date of birth (mm/dd/yyyy)

                                                                                                                                                     Male         Female
Mailing address (if different than residence address)                  City                    Zip


Date residence established (mm/dd/yyyy)                                                        Naturalization data (if applicable)


* Driver's license or Social Security number                                                                         I do not have a driver's license or Social Security number

Party Affiliation         choose one of the following:         Democratic              Republican               Libertarian             Reform               Not affiliated with a party

Signature        I swear or affirm that I am a citizen of the United States and a Kansas resident, that I will be 18 years old before the next statewide general election, that if convicted
                 of a felony, I have had my civil rights restored, that I have abandoned my former residence and/or other name, and that I have told the truth on this application.



Sign here                                                                                                                Date today
 Warning: If you submit a false voter registration application, you may be convicted and sentenced to up to 17 months in prison.
Complete if previously registered                    please print


Previous: Registration name                         Residence address                                    City                        State                  Zip              County

                                Ward                                 Pct                                  School Dist                         Member Dist
FOR OFFICE USE ONLY:
                                Sen                      Rep                     CoComm
ALLEN                     COFFEY                   GEARY                 JOHNSON                 MIAMI                    PRATT                      SHERMAN
1 N Washington            110 S 6th St Rm 202      PO Box 927            2101 E Kansas City Rd   201 S Pearl Ste 102      300 S Ninnescah Box 885    813 Broadway Rm 102
Iola 66749                Burlington 66839         Junction City 66441   Olathe 66061            Paola 66071              Pratt 67124                Goodland 67735
ANDERSON                  COMANCHE                 GOVE                  KEARNY                  MITCHELL                 RAWLINS                    SMITH
100 E 4th                 201 S New York Box 776   PO Box 128            304 N Main Box 86       111 S Hersey Box 190     607 Main                   218 S Grant
Garnett 66032             Coldwater 67029          Gove 67736            Lakin 67860             Beloit 67420             Atwood 67730               Smith Center 66967
ATCHISON                  COWLEY                   GRAHAM                KINGMAN                 MONTGOMERY               RENO                       STAFFORD
423 N 5th                 311 E 9th                410 N Pomeroy         130 N Spruce            217 E Myrtle Box 446     206 W First                209 N Broadway
Atchison 66002-1861       Winfield 67156           Hill City 67642       Kingman 67068           Independence 67301       Hutchinson 67501           St John 67576
BARBER                    CRAWFORD                 GRANT                 KIOWA                   MORRIS                   REPUBLIC                   STANTON
120 E Washington          111 E Forest Box 249     108 S Glenn           211 E Florida           501 W Main               PO Box 429                 201 N Main Box 190
Medicine Lodge 67104      Girard 66743-0249        Ulysses 67880         Greensburg 67054        Council Grove 66846      Belleville 66935-0429      Johnson 67855
BARTON                    DECATUR                  GRAY                  LABETTE                 MORTON                   RICE                       STEVENS
1400 Main Rm 202          PO Box 28                Box 487               501 Merchant Box 387    1025 Morton Box 1116     101 W Commercial           200 E 6th
Great Bend 67530          Oberlin 67749            Cimarron 67835-0487   Oswego 67356            Elkhart 67950            Lyons 67554                Hugoton 67951
BOURBON                   DICKINSON                GREELEY               LANE                    NEMAHA                   RILEY                      SUMNER
210 S National            109 E First Box 248      PO Box 277            144 S Lane Box 788      607 Nemaha Box 186       110 Courthouse Plaza       501 N Washington
Fort Scott 66701          Abilene 67410            Tribune 67879         Dighton 67839           Seneca 66538             Manhattan 66502            Wellington 67152
BROWN                     DONIPHAN                 GREENWOOD             LEAVENWORTH             NEOSHO                   ROOKS                      THOMAS
601 Oregon St             PO Box 278               311 N Main            300 Walnut              100 S Main Box 138       115 N Walnut               300 N Court
Hiawatha 66434            Troy 66087               Eureka 67045          Leavenworth 66048       Erie 66733               Stockton 67669             Colby 67701
BUTLER                    DOUGLAS                  HAMILTON              LINCOLN                 NESS                     RUSH                       TREGO
205 W Central             1100 Massachusetts St    219 N Main Box 1167   216 E Lincoln Ave       202 W Sycamore           715 Elm Box 220            216 Main
El Dorado 67042           Lawrence 66044           Syracuse 67878        Lincoln 67455           Ness City 67560          LaCrosse 67548             WaKeeney 67672
CHASE                     EDWARDS                  HARPER                                        NORTON                   RUSSELL                    WABAUNSEE
Courthouse Sq Box 547                                                    LINN
Cottonwood Falls 66845    312 Massachusetts        201 N Jennings        315 Main                105 S Kansas Box 70      4th & Main Box 113         215 Kansas Box 278
                          Kinsley 67547            Anthony 67003         Mound City 66056        Norton 67654             Russell 67665              Alma 66401
CHAUTAUQUA                ELK
215 N Chautauqua                                   HARVEY                LOGAN                   OSAGE                    SALINE                     WALLACE
Sedan 67361               127 N Pine Box 606       8th & Main Box 687    710 W 2nd               717 Topeka Ave Box 226   300 W Ash Ste 215          PO Box 70
                          Howard 67349             Newton 67114          Oakley 67748            Lyndon 66451-0226        Salina 67401               Sharon Springs 67758
CHEROKEE
100 W Maple Box 14        ELLIS                    HASKELL               LYON                    OSBORNE                  SCOTT                      WASHINGTON
Columbus 66725            PO Box 720               300 Inman Box 518     402 Commercial          423 W Main Box 160       303 Court St               214 C St
                          Hays 67601               Sublette 67877        Emporia 66801           Osborne 67473            Scott City 67871           Washington 66968
CHEYENNE
212 E Washington          ELLSWORTH                HODGEMAN              MARION                  OTTAWA                   SEDGWICK                   WICHITA
Box 985                   210 N Kansas             500 Main              Courthouse Box 219      307 N Concord Ste 130    510 N Main                 206 S 4th Drawer 968
St Francis 67756          Ellsworth 67439          Jetmore 67854         Marion 66861            Minneapolis 67467        Wichita 67203-3798         Leoti 67861
CLARK                     FINNEY                   JACKSON               MARSHALL                PAWNEE                   SEWARD                     WILSON
913 Highland St Box 886   311 N. 9th St., Box M    400 New York          1201 Broadway           715 Broadway             415 N Washington Ste 109   615 Madison
Ashland 67831-0886        Garden City 67846        Holton 66436          Marysville 66508        Larned 67550             Liberal 67901              Fredonia 66736
CLAY                      FORD                     JEFFERSON             MCPHERSON               PHILLIPS                 SHAWNEE                    WOODSON
712 Fifth Box 98          100 Gunsmoke             PO Box 321            117 N Maple             301 State St             911 SW 37th                105 W Rutledge Room 103
Clay Center 67432         Dodge City 67801         Oskaloosa 66066       McPherson 67460         Phillipsburg 67661       Topeka 66611-2378          Yates Center 66783
CLOUD                     FRANKLIN                 JEWELL                MEADE                   POTTAWATOMIE             SHERIDAN                   WYANDOTTE
811 Washington            315 S Main               307 N Commercial      PO Box 278              207 N 1st Box 187        925 9th St Box 899         9400 State Ave
Concordia 66901           Ottawa 66067             Mankato 66956         Meade 67864             Westmoreland 66549       Hoxie 67740                Kansas City 66112




     RON THORNBURGH                                                                                                                                       Post Office
                                                                                                                                                           Will Not
     Secretary of State                                                                                                                                     Deliver
                                                                                                                                                           Without
     Memorial Hall, 1st Floor                                                                                                                              Postage
     120 S.W. 10th Avenue
     Topeka, KS 66612-1594




                                                                      COUNTY ELECTION OFFICER


                                                                                                                KS