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    Voter Information

    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