VERMONT Application for Addition to the Checklist (VT VOTER REGISTRATION FORM) 17 V.S.A. § 2145
(Please print clearly, use ballpoint pen, and bear down hard.) I, ______________________________________________________________ apply to have my name (Last Name)
added to the checklist of the Town/City of ______________________________________. By checking the boxes below, I swear or affirm that these are true statements:
Are you a citizen of the United States?
Will you be eighteen years of age or older on or before the day of election?
Are you a resident of Vermont?
If you checked "No" in response to any of the three questions above, DO NOT complete this form. You are not qualified to vote in Vermont. Contact the Office of the Secretary of State, Elections Division, for more information at (800) 439-8683. ONLY if you are registering to vote for the 1st time in Vermont, AND you are mailing this application to your town clerk individually, you must submit a photocopy of one of the following: current & valid photo identification OR bank statement, utility bill, or government document with your name and current address. (Do not submit I.D. if you have been previously registered in VT, if this form is submitted as part of a voter registration drive, or if you return this form to the clerk’s office in person.) I was born on ________________________ at _________________________________ , ___________________________
(Town or City)
Mailing Address: ___________________________________________________________ Tel. #: ___________________ My principal dwelling is located at: ___________________________________________________________________________________________________ .
(E911 street address including number or exact physical location, if no E911 address) The last address I was registered to vote under was: __________________________________________________________.
(Physical location – include number, street, town, state and zip code) By registering to vote in the above named town in Vermont, I authorize my name to be removed from the list of registered voters in any previous place where I was registered to vote. I was registered in the past under a different last name of: __________________________. By checking the boxes, I swear or affirm that these are true statements:
I am a resident of the Town or City of _____________________________ AND
I have taken the Voter's Oath (see attestation below for new VT voters). My VT Driver’s License or Personal I.D. # (PID#) issued by VT DMV is__________________. This # is REQUIRED. I swear or affirm under penalty of perjury and other potential federal or state criminal penalties of up to a $10,000 fine, or imprisonment for not more than fifteen years, or both, that I do not have a VT Drivers License or PID# issued by VT DMV. (17 V.S.A. § 2145(f); 17 V.S.A. § 2011; 42 U.S.C. § 1973gg-10.) IF you do not have a VT Driver’s License or PID# issued by VT DMV, check the box above and enter the last 4 digits of your Social Security Number:________ . If you do not have a VT PID#, or SSN, please contact the Office of the Secretary of State, Elections Division, (800)439-8683. I meet all of the eligibility requirements to vote in this municipality. I hereby swear, or affirm, under penalty of perjury and other potential federal or state criminal penalties of up to a $10,000 fine, or imprisonment for not more than fifteen years, or both, that the statements made by me in this application are true. (17 V.S.A. § 2145(f); 17 V.S.A. § 2011; 42 U.S.C. § 1973gg-10). ____________________________
______________________________________________ Today’s Date
VOTER'S OATH (Vermont Constitution, Chapter II, Section 42): “You solemnly swear or affirm that whenever you give your vote or suffrage, touching any matter that...
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