Live Registration Evaluation Page

• Basic Information

First Name *

Middle Name

Last Name *

Suffix

Email Address

Phone Number *

Opt-in for SMS Messages

Gender

Race

• Eligibility

To vote in Pennsylvania, you must:

Be a United States citizen at least 30 days before the next election

and

Be at least 18 years of age on the day of the next election

and

Be a resident of Pennsylvania and your election district for at least 30 days before the next election

I am a United States citizen *

I will be 18 or older on Election Day. *

Date of Birth *

• Reason

You must select a reason

New Registration

Change of name

Previous registration First Name *

Previous registration Middle Name

Previous registration Last Name *

Change of address

Previous address *

Previous City *

Previous State *

Previous ZIP *

Previous County *

PA Voter No.

Year

Change of party

Federal or State employee registering in county of last residence

• Address

This must be the permanent address where you live, not a PO box.

I receive mail at a different address

Street Address *

Street Address 2

Unit Type

Unit Number

City *

Zipcode *

County *

Mailing Address *

Mailing City *

Mailing State *

Mailing Zipcode *

• Political Party

Choose Party *

If Other please specify *

• Voter Assistance

The county where you vote is required to provide assistance for the following:

Visual or hearing impairments
Physical disabilities, including wheelchair use
Difficulty reading
Difficulty reading, speaking, or understanding English

I require assistance to vote

Assistance Needed For: *

Preferred Language *

• Be a poll worker

I would like to be a poll worker on Election Day.

I would like to be a bilingual interpreter on Election Day.

I speak this language *

• Help with this form

Did someone help you with this form?

Assisted Person Name *

Assisted Person Address *

Assisted Person Phone *

If you helped a voter complete this voter registration application, you must also sign the application. By checking the box, you are signing the application electronically. In do so: You understand that your electronic signature on this application will constitute the legal equivalent of your signature. You agree to sign this application by electronic means and that all laws of the Commonwealth of Pennsylvania will apply.

I confirm that I have read and agree to the terms above *

• Signature

I declare that

I am a United States citizen and will have been a citizen for at least 1 month on the day of the next election.
I will be at least 18 years old on the day of the next election.
I will have lived at the address in section 4 for at least 30 days before the election.
I am legally qualified to vote.

I affirm that this information is true. I understand that this declaration is the same as an affidavit, and, if this information is not true, I can be convicted of perjury, and fined up to $15,000, jailed for up to 7 years, or both.By checking the box below, you are signing the application electronically. In doing so:

You agree you have read and accept the terms of the declaration above.
You understand that your electronic signature on this application will constitute the legal equivalent of your signature for this voter registration application.
You agree to conduct this voter registration transaction by electronic means and that all laws of the Commonwealth of Pennsylvania will apply to this transaction.

If you provided your PA driver’s license or PennDOT ID number, you understand that the signature from the PennDOT record will constitute your signature on your voter registration record. If you upload an image of your signature, you understand that the signature you upload will constitute your signature on your voter registration record. You understand that you do not have to register electronically, and may use a paper or other non-electronic form of this voter registration application.

I CONFIRM THAT I HAVE READ AND AGREE TO THE TERMS ABOVE. *

Provide one of the following identifications:

Pennsylvania Driver's License or ID Number *

I don't have a PennDOT issued ID

If you don't have a PennDOT number, please enter the last 4 digits of your Social Security Number *

I don't have a PennDOT issued ID or a Social Security Number

If you do not provide a PennDOT ID number, or if the number you provide is not correct, your county will contact you to complete your application. Your application will not be complete until your county receives your signature.

Provide your signature

I have read these terms and wish to proceed *

Signature *

Use your mouse or finger to sign in the box provided

By submitting this form, I agree to receive periodic emails from the VOTE.pa Team. I understand that I may unsubscribe at any time. Or register to vote using the Pennsylvania Department of State’s online voter registration form.