The Indiana Republican Party

Please fill out and press the print button at the bottom of the form. Sign and mail your printed form to:
Indiana Election Division
302 West Washington Street, Room E204
Indianapolis, Indiana 46204-2743
Registration forms MUST be received by October 6th, 2008

Indiana Voter Registration Application

Check boxes that apply:
New registration
Address change
Name change

County of Residence:
Gender:
Birthdate (mm/dd/yyyy):	/ /
Phone (10 digits, no spaces):
Email:

Applicant Name

First	Middle or Initial	Last	Suffix

Original First (see instruction A)	Original Middle	Original Last	Original Suffix

Residence Address (No Post Office Boxes)

Street	Apt No.	City / Town	State	Zip

Mailing Address

Check here if same as Residence
Street	Apt No.	City / Town	State	Zip

Previous Voter Registration Address

Street	County	Apt No.	City / Town	State	Zip

ID Information

Are you including identification documentation? (see instruction B):
Are you a citizen of the United States of America?:
Will you be at least 18 years of age on or before election day?:
Voter ID Type (see instruction C):
Voter ID:

Applicant Assistant

Name (see instruction D)	Street	City / Town	Phone (10 digits, no spaces)

Instructions:

A. Original Name:
If you have changed your name, what was your name before you changed it? If you have not changed your name, skip this question. Back to Original Name

B. Identification Documentation:
If you are registering to vote in Indiana for the first time, and you are sending this application by mail, you must provide identification documentation. Identification may include a current and valid photo id, current utility bill, bank statement, government check, paycheck, or government document that shows the name and address of the voter. You may include a copy of your identification with this application. Do not mail an ORIGINAL copy of your document! If you do not provide identification with this application or to the county voter registration office before election day, you will be asked for it the first time you vote. Back to Identification Documentation

C. Voter ID Type:
Provide your 10-digit Indiana issued driver's license number. If you do not posses an Indiana driver's license, then provide the last 4 digits of your social security number. Back to Voter ID Type

D. Applicant Assistant:
If applicant is unable to fill out the application due to disability, the person who helped the applicant with this application lists their name, address and telephone number in the box below. (Telephone number is optional.) Back to Applicant Assistant