STATE OF OHIO
MONTGOMERY COUNTY BOARD OF ELECTIONS
VOTER REGISTRATION APPLICATION FORM

1. Are you a U.S Citizen? Yes No 2. Will you be at least 18 years of age on or before the next general election? Yes No If you answer NO to either of the questions, do not complete this form.

3. Last Name	First Name	Middle Name or Initial	Jr., II, etc.
4. House Number and Street (Enter new address if changed	Apt. or Lot #	5. City or Post Office	6. Zip Code
7. Additional Rural or Mailing Address (if necessary)		8. County where you live
9. Birthdate (MM/DD/YYYY)	10. Ohio Driver's License No. OR last 4 digits of Social Security No. (Required)
11. Phone Number (voluntary)

ADDRESS CHANGE ONLY - PREVIOUS ADDRESS Previous House Number and Street   Previous City or Post Office County State

13. CHANGE OF NAME ONLY Former Legal Name