Alaska Voter Registration Application Form

                                    Revised December 2, 1998



                             NOTE: This form is not an electronic form.
                             It must be mailed, faxed or hand-delivered.



  1.Name (Last, First, MI, Suffix): _______________________________________ 
  2.Previous Name: _____________________________________________________ 
  3.Alaska Voter # ______________________________ 
  4.Alaska Residence Address (Where you live - DO NOT USE PO, PSC, or RR Box):
     __________________________________________________ 
  5.Mailing Address (include zip code): 
     __________________________________________________ 

  Optional, confidential information, for
  identification only:

  Social Security Number: ___________________
  Place of Birth: ___________________________
  Date of Birth (MO/DD/YR): _________________
  Daytime Phone Number: _____________________
  Evening Phone Number: _____________________
                                                         |FOR OFFICE USE ONLY
                                                         |VN_____________________
                                                         |D/P____________________
                                                         |Codes/Comments/Init
                                                         |
                                                         |
                                                         |Received Date
                                                         |
                                                         |_______________________

  6. Sex: 
       [ _ ] Male 
       [ _ ] Female 

                        7. Party Affiliation: 
                             [ _ ] Alaskan
                             Independence 
                             [ _ ] Democrat 
                             [ _ ] Green 
                             [ _ ] Republican 


                                                         [ _ ] Republican Moderate
                                                         [ _ ] Non-Partisan
                                                         [ _ ] Undeclared
                                                         [ _ ] Other: ____________________ 


  8.I am currently registered to vote in another state; please cancel that registration
     (City, State, County, Zip Code):
     _____________________________________________________________ 
  9.If you need special assistance, indicate the type of assistance needed: 
     _____________________________________________________________
     Phone number: _______________________________________________ 
 10.If you would like to serve on an election board, please provide your phone number:
     __________________________________________

 11.Voter Certification: Read and Sign Below
     I certify, under penalty of perjury, that: I am a United States Citizen; I am a
     resident of Alaska; I will be at least 18 years old within 90 days of this
     registration; I am not a convicted felon (unless unconditionally discharged); and I am
     not registered to vote in another state, or I have included the necessary information
     to cancel that registration. WARNING: If you provide false information on this
     application, you can be convicted of a misdemeanor.

     SIGNATURE: __________________________________________ DATE: _______________