In Box 4c fill in the name of the municipality (city, borough ortownship) and county where you live. Use the map in the box below ifyou cannot otherwise identify your address.

4a Address of Residence: Fill in your complete address of residence.P.O. boxes may not be used here unless there is no physical address.Print street address, city and zip code. (If the residence is only a portion of the house, include the location of the room, apartment or floor which is occupied.) 4b Although providing your telephone number is optional, it is a quick and easy way for your county to contact you if there is missing information on your registration form.

3b Pennyslvania Driver’s License OR Social Security Number: You must supply a PA Driver’s License Number if you have one. If you do not have a PA Driver’s License Number, you must supply the last four digits of your Social Security Number. If you do not have a Social Security Number, please check the box to the right of 3b.

If you require assistance when voting, you must check the box and provide the reason.

If you were assigned a Voter Identification Number, which appears on your Voter Identification Card, place that Identification Number, if available here. If you are applying to register to vote for the first time, leave this box blank.

Registration Declaration: You must be a citizen of the United States to register to vote in the Commonwealth of Pennsylvania. Please read the registration declaration carefully. You must sign and print your name and date the application.

Name of Assistant: If the applicant is unable to complete or sign the application, the person who assisted the applicant must provide his or her name, address and signature.

Prior Registration: If you were registered before, fill in the name used on your previous registration in Box 8a and address, county and year of previous registration in Box 8b.

PENALTY FOR FALSIFYING REGISTRATION DECLARATIONWARNING: If a person signs an official registration application knowing a statement declared in the application to be false, makes a false registration, or furnishes false information, the person commits perjury. Perjury is punishable, upon conviction, by a term of imprisonment not exceeding seven years, or a fine not exceeding $15,000, or both, at the discretion of the court. Submitting an application containing false information may also subject a person to other penalties, including loss of the right of suffrage, under state or federal law.

REGISTERANDVOTE

PENNSYLVANIA VOTER REGISTRATIONMAIL APPLICATION

To Register You Must:• Be a citizen of the United States for at least one month before the next election;

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

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

GENERAL INSTRUCTIONSwww.VotesPA.com

1. Please provide all information on the application as required. Read all instructions carefully before you fill out the application.

2. If you are currently registered, you do not need to re-register unless you have moved or changed your name since you last registered.

3. In order to vote in the next election, this application must be received by your county voter registration office no later than 30 days before the election, or postmarked no later than the thirtieth day before the election. Military electors may apply at any time. For more information on military and overseas electors, see www.fvap.gov.

4. Write the mailing address for your county voter registration office on the reverse side of this application and place the proper postage in the designated area. Addresses for all Pennsylvania counties are listed on the back of this form.

5. You are not registered to vote until your application has been processed and accepted by the county voter registration office. If accepted, the county voter registration office will send you, via nonforwardable mail, a Voter Identification Card. If you do not receive a Voter Identification Card within 14 days of the date you submit this application, contact your county voter registration office.

6. If you decline to register to vote, your decision will remain confidential. If you register to vote, the office at which you register will remain confidential and be used for voter registration purposes only.

7. Do not use staples or duct tape.8. Print and sign clearly in blue or black pen.

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PENNSYLVANIA VOTER REGISTRATION APPLICATION

Are you a citizen of the United States of America? Yes NoWill you be 18 years of age on or before election day? Yes No

New Registration Change of Name Change of Address Change of Party I am a Federal or State employee and wish to retain my voting residence in the county where I last resided.

} If you checked “No” in response to either of these questions, do not complete this form.

Last Name

Place PA Driver’s License (DL) # hereif you have one:

If no PA DL #, Place SS# (last 4 digits) here:

First Name Middle Name/Initial

Address of residence, include street and city (Use map above if no street number or name) (If only P.O. box, see above) Apt # State Zip Code Telephone Number (Optional)

PA ( )

Jr Sr II III IV(circle if applicable)

Municipality where you live County where you live Mailing Address (if different than address of residence) City State Zip Code

Date of Birth Race (Optional) Name on previous registration

/ /Address of previous registration (include street and city)

County of previous registration Year of previous registration

Name and signature of person who assisted in the completion of this application

Address

In which party do you wish to register?

Democratic Republican Libertarian No affiliation Other

Print Your Name Below Date:

/ /

X

Voter Identification Number (If available - not necessary if you are registering to vote for the first time or if you do not know your number.)

13 Do you require assistancewhen voting? Yes No

Reason for assistance:

I DO NOT have a PA Driver’s License or Social Security Number.

You must register with a party if you want to take part in that party’s primary.

I HEREBY DECLARE THAT:(1) On the day of the next election I will have been a United States citizen for at least one month. I will be at least 18 years of age, and I will have resided in Pennsylvania and in my election district for at least 30 days;

(2) I am legally qualified to vote.

AND I HEREBY AFFIRM THAT the information I have provided in this registration declaration is true. I understand that this registration declaration will be accepted for all purposes as the equivalent of an affidavit; and if the registration contains a materially false statement, I will be subject to penalties for perjury.

Place signatue with full name (or mark) below(Please see Penalty for Falsifying Declaration.)

IDENTIFICATION WHEN YOU VOTE

For more information on voting, please visit our educational web site: www.VotesPA.com.

If you do not receive your voter ID card in the mail within two weeks, call your county voter registration or our toll-free hotline 1-800-552-VOTE.

If you are interested in becoming a poll worker or a bilingual interpreter on Election Day, please check the boxes. Your county voter registration will contact you.

Although providing your e-mail address is optional, it is a quick and easy way for your county voter registration to contact you in case there is missing information on your registration form:

•••

•

I would like to be a poll worker on Election DayI would like to be a bilingual interpreter on Election Day

Specify Language:

DSBE-600 2/09residence.)

LEBANON COUNTY400 S 8TH ST LEBANON PA 17042-6794(717) 274-2801 EXT 4428

LEHIGH COUNTY17 S 7TH ST ALLENTOWN PA 18101-2401(610) 782-3194

MERCER COUNTY5 COURTHOUSEMERCER PA 16137-1227(724) 662-3800 EXT 2240

MIFFLIN COUNTY20 N WAYNE STLEWISTOWN PA 17044(717) 248-6571

MONROE COUNTYONE QUAKER PLAZA RM 105STROUDSBURG PA 18360-2170(570) 517-3165

MONTGOMERY COUNTYCOURTHOUSE PO BOX 311NORRISTOWN PA 19404-0311(610) 278-3280

MONTOUR COUNTY29 MILL STDANVILLE PA 17821(570) 271-3000

NORTHAMPTON COUNTY

E A S T O N PA 18042-(610) 559-3055

NORTHUMBERLAND COUNTY609 MARKET STSUNBURY PA 17801-2360(570) 988-4208

PERRY COUNTYPO BOX 37NEW BLOOMFIELD PA 17068-0037(717) 582-2131 EXT 4110

PHILADELPHIA COUNTY520 N DELAWARE AVE 5TH FLPHILADELPHIA PA 19123-4295(215) 686-1591

PIKE COUNTY506 BROAD STMILFORD PA 18337-1535(570) 296-3426

POTTER COUNTY1 NORTH MAIN STCOUDERSPORT PA 16915(814) 274-8467

SULLIVAN COUNTYPO BOX 157LAPORTE PA 18626-0157(570) 946-5201

SUSQUEHANNA COUNTYPO BOX 218 MAPLE STMONTROSE PA 18801-0218(570) 278-4600 EXT 220

TIOGA COUNTY118 MAIN STWELLSBORO PA 16901-0589(570) 723-8230

UNION COUNTY155 N 15TH STLEWISBURG PA 17837-8822(570) 524-8681

VENANGO COUNTY1174 ELK ST PO BOX 831FRANKLIN PA 16323-0831(814) 432-9514

WARREN COUNTY204 4TH AVEWARREN PA 16365-2399(814) 728-3406

WASHINGTON COUNTY100 W BEAU ST RM 206WASHINGTON PA 15301(724) 228-6750

WAYNE COUNTY925 COURT ST HONESDALE PA 18431-1996(570) 253-5978

WESTMORELAND COUNTY2 N MAIN ST STE 109GREENSBURG PA 15601(724) 830-3150

WYOMING COUNTY1 COURTHOUSE SQTUNKHANNOCK PA 18657-1216(570) 996-2226

YORK COUNTY28 EAST MARKET STYORK PA 17401-1579(717) 771-9604

670 WOLF AVE4343

COLUMBIA COUNTY35 W MAIN ST PO BOX 380BLOOMSBURG PA 17815-0380(570) 389-5640

CRAWFORD COUNTY903 DIAMOND PARKMEADVILLE PA 16335-2678(814) 333-7306

CUMBERLAND COUNTY310 ALLEN RDCARLISLE PA 17013-3044(717) 240-6385

DAUPHIN COUNTYPO BOX 1295HARRISBURG PA 17108-1295(717) 780-6360

DELAWARE COUNTYGOVT CENTER BLDG 201 W FRONT STMEDIA PA 19063-2728(610) 891-4659

ELK COUNTY300 CENTER ST PO BOX 448RIDGWAY PA 15853-0448(814) 776-5337

ERIE COUNTY140 W 6TH ST RM 105ERIE PA 16501-1096(814) 451-6276

FULTON COUNTY116 W MARKET ST STE 203MCCONNELLSBURG PA 17233(717) 485-3691

GREENE COUNTY93 E HIGH ST RM 102WAYNESBURG PA 15370(724) 852-5230

HUNTINGDON COUNTY223 PENN ST COURTHOUSEHUNTINGDON PA 16652-1486(814) 643-3091

INDIANA COUNTY825 PHILADELPHIA ST INDIANA PA 15701-3934(724) 465-3852

JEFFERSON COUNTY155 MAIN ST JEFFERSON PLACEBROOKVILLE PA 15825-1269(814) 849-1605

JUNIATA COUNTYBRIDGE ST PO BOX 68MIFFLINTOWN PA 17059(717) 436-7706

LACKAWANNA COUNTY135 JEFFERSON AVE STE 100SCRANTON PA 18503(570) 963-6737

LANCASTER COUNTY150 NORTH QUEEN ST STE 102LANCASTER PA 17603-3562(717) 299-8293

LAWRENCE COUNTY430 COURT ST NEW CASTLE PA 16101-3593(724) 656-2161

FAYETTE COUNTY22 E MAIN ST PUBLIC SERVICE BLDGUNIONTOWN PA 15401(724) 430-1289

FOREST COUNTY526 ELM ST BOX 3TIONESTA PA 16353(814) 755-3537

FRANKLIN COUNTY157 LINCOLN WAY EASTCHAMBERSBURG PA 17201-2211(717) 261-3886

LUZERNE COUNTY20 N PENNSYLVANIA AVE STE 207WILKES-BARRE PA 18701-3505(570) 825-1715

LYCOMING COUNTY48 W THIRD STWILLIAMSPORT PA 17701-0536(570) 327-2267

MCKEAN COUNTY500 W MAIN ST COURTHOUSESMETHPORT PA 16749(814) 887-3203

SCHUYLKILL COUNTY420 N C E NT S T POTTSVILLE PA 17901(570) 628-1467

SNYDER COUNTYPO BOX 217 MIDDLEBURG PA 17842-0217(570) 837-4209

SOMERSET COUNTY300 N CENTER AVE STE 340SOMERSET PA 15501(814) 445-1549

R E

ADDRESSES OF COUNTY VOTER REGISTRATION OFFICESTo mail this application, write the address of the County Voter Registration Office in the proper area on the reverse side of this form.

ADAMS COUNTY111-117 BALTIMORE STGETTYSBURG PA 17325-2312(717) 337-9832

ALLEGHENY COUNTY542 FORBES ST STE 609P IT T S B U R G H PA 15219-29(412) 350-4500

ARMSTRONG COUNTY450 E. MARKET ST, STE 207KITTANNING PA 16201(724) 548-3222

BEAVER COUNTY810 THIRD STBEAVER PA 15009(724) 728-5700

BEDFORD COUNTY200 SOUTH JULIANA ST 3RD FLOORBEDFORD PA 15522(814) 623-4807

BERKS COUNTY633 COURT STREADING PA 19601(610) 478-6490

BLAIR COUNTY423 ALLEGHENY ST STE 043HOLLIDAYSBURG PA 16648-2022(814) 693-3150

BRADFORD COUNTY301 MAIN ST TOWANDA PA 18848-1878(570) 265-1717

BUCKS COUNTY55 E COURT ST DOYLESTOWN PA 18901-4318(215) 348-6163

BUTLER COUNTYPO BOX 1208BUTLER PA 16003-1208(724) 284-5308

CAMBRIA COUNTY200 S CENTER STEBENSBURG PA 15931(814) 472-1464

CHESTER COUNTY601 WESTTOWN RD STE 150PO BOX 2747WEST CHESTER PA 19380-0990(610) 344-6410

CLARION COUNTY421 MAIN ST STE 19CLARION PA 16214-1093(814) 226-4000 EXT 2205

CLEARFIELD COUNTY230 E MARKET ST STE 108CLEARFIELD PA 16830(814) 765-2641 EXT 5996

CLINTON COUNTY232 E MAIN ST GARDEN BLDG 3RD FLLOCK HAVEN PA 17745-1385(570) 893-4019

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CAMERON COUNTY20 E FIFTH STEMPORIUM PA 15834-1469(814) 486-2315

CARBON COUNTY

JIM THORPE PA 18229-0170(570) 325-4801

CENTRE COUNTY420 HOLMES STBELLEFONTE PA 16823-1488(814) 355-6703

76 SUSQUEHANNA ST PO BOX 170

For a listing of availablecounty e-mail addresses, go to:www.VotesPA.com