SEE THE OTHER SIDE OF THIS PAGE FOR INSTRUCTIONS 
QUESTIONS? - Call your parish Registrar of Voters Office or call the
Secretary of State at 1-800-883-2805 or (225) 922-0900.

Louisiana Voter Registration Application(LA-VRA - Rev. 4/17)
OFFICIAL USE ONLY:

WD: ___________________ PCT: ___________________ REG. TYPE: ___________________ IN/OUT: ___________________ REG # ___________________

Please print clearly in ink, preferably black.

Eligibility

1.

Name

2.

ResidenceAddress

 Yes  No
 Yes  No

Are you a citizen of the United States of America?
Will you be 18 years of age on or before election day?

FIRST NAME:

FULL MIDDLE OR
MAIDEN NAME:SUFFIX (Sr., Jr.,II)

UNIT/APT #:STATELA DL/ID
Card #
Place of Last
Residence
Affirmationand Signature(read and sign or
make your mark)

ZIP CODE:HOUSE # &STREET/P.O. BOX:

UNIT/APT #:STATE:

4. _______/_______/_________ 5. *SSN
MMMother’sMaiden Name

LA

 DEM

8.  REP

DD___________ - ________ - ____________
XXXXX
XXXX

YYYY

 GRN  IND
 NO PARTY

 LBT

9.

 OTHER (Specify) ____________________________

10.

____________________________ZIP CODE:

6. SexM
F

 WHITE  BLACK  ASIAN HISPANIC  AMERICAN INDIAN(Optional)
 OTHER ________________________

7. Race

Place CITY/TOWN:
of Birth

STATE:

PARISH/COUNTY:

11. Email(Optional) _______________________________

COUNTRY:

12. Phone

Home: (________) _________ - ___________(Optional)

Other: (________) _________ - ___________
Do you need  No
13. _________________________________________ 14. assistance in I do not have a LA DL/ID card
 Yes, Reason: _____________________________________________
voting?

15.

HOUSE #& STREET:
CITY:

STATE:

Place
STATE:
16. of Last
PARISH/Registration COUNTY:

Former
17. Registered
Name, if any

I do hereby solemnly swear or affirm that I am a United States citizen, that I am of eligible age to register to vote, that I am not currently under an order of imprisonment
for conviction of a felony, that I am not currently under a judgment of full interdiction or limited interdiction where my right to vote has been suspended, that I am a bonafide resident of this state and parish, and that the facts given by me on this application are true to the best of my knowledge and belief. If I have provided false information,
I may be subject to a fine of not more than $2,000 ($5,000 for subsequent offense) or imprisonment for not more than 2 years (5 years for subsequent offense), or both.
18. Any false statement may constitute perjury.
ApplicantSignature: Witnesses(If your signature isa mark, you musthave two witnessessign)

Give Location (If Necessary)

3.  Check if no postal service at your residence address above and supply mailing address here.

CITY/TOWN:

PartyAffiliation

If you answered “No” to these questions, do not complete this form. You are noteligible to vote at this time.

LAST NAME:

CITY/TOWN:(If different fromResidence Address)

Birthdate Updating Voter Registration

HOUSE # &STREET (NO P.O. BOX):(Where you live andclaim homesteadexemption, if any)

Mailing
Address

Reason for Application:  New Voter Registration

19.

Date:

Witness #1
Signature: Witness #1
Print Name:

Witness #2
Signature: Witness #2
Print Name:* Last 4 digits of the social security number are required, if issued, and you have no LA driver's license or LA special ID; full SSN number is preferred but optional.
Note: If you decline to register to vote, this fact will remain confidential and will be used only for voter registration purposes. If you register to vote, the office where your application was submitted
will remain confidential and will be used only for voter registration purposes. You may request a copy of your voter registration form at any time from the registrar of voters.
OFFICIAL USE ONLY

OFFICIAL USE ONLYCHECK
New Registration
ONE
REMARKS:REMARKS:CIRCLEONE:ONE:CIRCLE
PA
MN
RG
PAMV
RG

UpdatedAddress
Change Name
Change Party
Change Changeto Assistance
Voting in Assistance in Voting NewRegistration:
Registration Updated
Registration:
Address
Change NameChange Party
Change inChange

SDA
SDA

SS (Disability)
SS (Disability)

Provided by the Louisiana Secretary of State

Received by: _______________________________ Date: _________________________
Received by: __________________________________________________ Date: _________________________
Approved by the Louisiana Attorney GeneralLA-VRA - Rev. 4/17

Louisiana Voter Registration Application(LA-VRA - Rev. 4/17)

QUESTIONS? - Call your parish Registrar of Voters Office or callthe Secretary of State at 1-800-883-2805 or (225) 922-0900.

APPLICATION INSTRUCTIONSUSE THIS LOUISIANA VOTER REGISTRATION APPLICATION TO: 1) register to vote; 2) change your address; 3) request a name change; 4) change party affiliation; or 5)
request assistance in voting.
TO REGISTER AND BE ELIGIBLE TO VOTE AN APPLICANT MUST: 1) be a U.S. citizen; 2) be 17 years old (16 years old if registering to vote in person at the Registrar’s
Office or the Office of Motor Vehicles), but must be 18 years old before actually voting; 3) not be under an order of imprisonment for conviction of a felony; 4) not be under ajudgment of full or limited interdiction where your right to vote has been suspended; 5) reside in the state and parish in which you seek to register and vote.
Instructions: the grey section numbers on this page correspond to the grey section numbers on the application.
Reason for Application: Check “New Voter Registration”, if this is a first time registration or if a new registration in a new parish after moving. Check “Updating VoterRegistration”, if you are making any change to your present registration. If new registration, fill out the form completely.
Eligibility - Federal law requires you to affirm that you are a citizen of the United States of America and that you will be 18 years of age on or before the election day in

1. which you are eligible to vote. If you answered “No” to these questions, do not complete this application form. You are not eligible to vote at this time. If you are registering
2.

3.

4.
5.

as a 16 or 17 year old, you may check “Yes” because you will not be allowed to vote until you are 18.
Name - You must provide your full name. Do not use nicknames or initials for middle or maiden name. If this application is for a change of name, please also complete
section 17: “Former Registered Name”.
Residence Address - “Residence Address” means the address (Number, Street, City, State and Zip) where you live and are registering to vote. Residence address must
be the address where you claim homestead exemption, if any, except for a resident in a nursing home or veterans’ home who may choose to use the address of thenursing home or veterans’ home or the home where they have a homestead exemption. A college student may elect to use their home address or their address at school
while attending. Do not use a post office box for your “Residence Address”. If you use a rural route and box number, you may draw a map in box labeled “Give Location” toprovide the exact location. Write in the names of the crossroads (streets) nearest to residence. Draw an X to show residence. Use a dot to show any schools, churches,stores or landmarks near residence and write the name of the landmark.
Mailing Address - If you check that you do not receive postal service at your residence address, you must provide your mailing address (Number, Street, City, State andZip). Otherwise a mailing address may be provided and you may use a Post Office Box for a mailing address.
Birthdate - Print your date of birth. The month and day of your birth remains confidential by law.
Social Security Number - If you do not have a LA driver's license or LA special identification card, you must provide the last four digits of your social security number, ifissued. The full social security number is preferred and may be provided on a voluntary basis and will be kept confidential. If you were not issued a social security number,you must attach either one or more documents to prove your identity, residence and date of birth. Documents may be: a) a copy of current and valid photo identification
and/or b) a copy of a current utility bill, bank statement, government check, paycheck, or other government document. Your SSN number remains confidential and is onlyused for registration purposes.
Sex - Check male or female (for statistical purposes only).

6.
7. Race - Race/Ethnic origin is optional (for statistical purposes only).

Party Affiliation - If you are registering for the first time, you may choose a party affiliation of Democrat, Green, Independent, Libertarian or Republican parties. You may
specify any other party affiliation by checking “other” and then listing the party you wish to affiliate. If you do not want to register with a political party affiliation check “No
8.
Party”, or if you do not complete this section, your party affiliation will be listed as “no party”. If you are already registered with a party affiliation and no political party
change is being made with this application, you may leave this section blank or re-enter your political party affiliation.
9. Place of Birth - Print the city/town, parish/county, state and country of your birth place (for statistical purposes only).

10. Mother’s Maiden Name - Print your mother’s maiden name, which is her last name at her birth. If unknown, write “unknown”.
11.
12.
13.
14.
15.
16.
17.
18.
19.

Email - Give your email address for election officials to contact you if there is a problem with your registration. Email addresses are protected from disclosure by law andare for official use only.
Phone - Give your phone numbers for election officials to contact you if there is a problem with your registration. Phone numbers are optional and a public record unless
you make a request for your phone numbers to be kept confidential by election officials.
LA DL/ID Card # - Print your LA driver’s license or LA special identification card number, if issued. If you do not have one, check “I do not have a LA DL/ID card”. This ID
number remains confidential and is for official use only.
Assistance in Voting Needed? - Indicate if you will need assistance in voting by checking either the “No” or “Yes” box. If “Yes”, write the reason for needing assistance. The
registrar of voters in your parish may contact you for proof of disability.
Place of Last Residence - Print the address (number and street), city, and state of your prior residence, if different from residence address in section 3 or write “Same”.
Place of Last Registration - Print the state and parish (or county) of your last registration if you were registered in another parish or state prior to completing thisapplication. Important: Contact the local election office in your prior state and cancel your prior registration. Registering in Louisiana does not automatically cancel ortransfer your voter registration from another state.
Former Registered Name - If you are using this application to make a name change to your registration, print your former registered name (name you are changing) in thissection. If name changed by court order, provide a copy of the order with this application.
Affirmation and Signature - Read the affirmation and sign your full name or make your mark and print the date this application was signed and completed. If assistance inregistering is being provided, make sure the applicant understands what they are affirming and that they meet the requirements to register to vote.
Witnesses - If you are unable to sign your name, you may make your mark, but it must be witnessed by two people or it is not valid.

Mailing Instructions - If returned by mail, place in an envelope and mail to your Registrar of Voters Office. You can find your registrar of voters mailingaddress on the Registrar of Voters Address Page, by visiting our website at www.geauxvote.com or by calling the toll free at 1-800-883-2805. Yourapplication or envelope must be postmarked 30 days prior to the first election in which you seek to vote.
Online Voter Registration - Voter registration is also available at www.geauxvote.com and you may register online before the 20th day prior to the election.
Please call your registrar of voters if you do not receive your voter information card two weeks after registering.
Provided by the Louisiana Secretary of State

Approved by the Louisiana Attorney General

LA-VRA - Rev. 4/17