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Florida Voter Registration Application
Part 1 – Instructions (DS-DE #39, R1S-2.040, F.A.C. (eff. 01/2012) To Register in Florida, you must be:  A U.S. citizen,  A Florida resident, and  At least 18 years old (you may also preregister if you are 16 or 17 years old but you cannot vote until you are 18). If you have ever been convicted of a felony or if a court has ever found you to be mentally incapacitated as to your right to vote, your right to vote must be restored before you can register. If you do not meet any one of these requirements, you are not eligible to register. Where to Register: You can register to vote in-person or by mailing or hand-delivering your application to any supervisor of elections’ office, any office that issues driver’s licenses any voter registration agency (for example, any public assistance office, assisted living facility, office serving persons with disabilities, public library, or armed forces recruitment office) or the Division of Elections. If mailing application, be sure to add sufficient postage. Deadline to Register: The deadline to register to vote is 29 days before an upcoming election. You can update your registration record at any time, but to change your political party for a primary election, you must make the change by the registration deadline. For a new application, you will be contacted if your application is incomplete, denied or a duplicate of an existing registration. If you receive a voter information card, that means you are registered to vote.

Información en español: Sirvase llamar a la oficina del supervisor de elecciones de su condado si le interesa obtener este formulario en español. Political Party Affiliation: Florida is a closed primary election state. That means registered voters affiliated with a political party can only vote for that party’s candidates in a partisan race on a primary election ballot. However, regardless of the political party with which you registered, you can still vote in the primary election on any issue, any nonpartisan race or any race where the candidate will face no opposition in the general election. Indicate the political party with which you wish to be registered. If you leave the political party affiliation field blank, you will be registered without any party affiliation. For a list of political parties registered in Florida, go to the Division of Elections’ website under the heading For the Voters at: http://election.dos.state.fl.us/ Race/Ethnicity: You are not required to list your race or ethnicity. However, if you choose to do so, please choose only one from the list. Public Record Notice: This application becomes a public record when filed. However, the following information is not available to the public and is used only for voter registration purposes: your FL DL#, FL ID# and SSN, where you registered to vote, and whether you declined to register or update your voter registration record when asked by a voter registration agency. Your signature can be viewed but not copied. (Section 97.0585, Fla. Stat.) Criminal Offense: It is a 3rd degree felony to submit false information. Penalties include fines up to $5,000 and/or up to 5 years of prison. Questions: For more information, contact your local supervisor of elections http://election.dos.state.fl.us/SOE/supervisor_elections.shtml or refer to the Division of Elections’ website at: http://election.dos.state.fl.us.

Identification (ID) Requirements: If you are a new applicant, state and federal law require you to provide a current and valid Florida driver’s license number (FL DL#) or Florida identification card number (FL ID#). If you have not been issued a FL DL# or FL ID#, you must then provide the last four digits of your Social Security Number (SSN). If you have not been issued any of these ID numbers, check “None” on the application. If you do not provide any number or do not check “None,” your registration may be denied. See s.303, HAVA and section 97.053(6), Fla. Stat. Special ID requirements: If you are registering by mail, have never voted in Florida, and have never been issued one of the ID numbers above, you must include with your application, or at a later time before you vote, one of the following:  A copy of an ID that shows your name and photo (acceptable IDs)--U.S. Passport, debit or credit card, military ID, Student ID, retirement center ID, neighborhood association ID, or public assistance ID; or  A copy of an ID that shows your name and current residence address (acceptable documents)--utility bill, bank statement, government check, paycheck, or other government document. You do not have to provide the special ID to register if you are 65 or older, have a temporary or permanent physical disability, are a member of the active uniformed services or merchant marine who is absent from the county for active duty, or a family member thereof, or are currently living outside the U.S. but otherwise eligible to vote in Florida. If you vote at the polls, you will still need to show a photo/signature ID as is required of all voters.

All shaded lettered boxes are required for a new registration.

Florida Voter Registration Application
Part 2 – Form (DS-DE #39, R1S-2.040, F.A.C. (eff. 01/2012)

The downloadable/printable online form is available at: http://election.dos.state.fl.us/pdf/webappform.pdf

This is:

New Registration  Record Update/Change (e.g., Address, Party Affiliation, Name, Signature) Request to Replace Voter Information Card OFFICIAL USE ONLY  YES  NO A Are you a citizen of the United States of America? B  C  D E F G
Last Name Address Where You Live (legal residence-no P.O. Box) Mailing Address (if different from above address) Address Where You Were Last Registered to Vote Former Name (if name is changed) Party Affiliation (Check only one. If left blank, you will be registered without party affiliation) I affirm that I am not a convicted felon, or if I am, my right to vote has been restored. I affirm that I have not been adjudicated mentally incapacitated with respect to voting or, if I have, my right to vote has been restored.

Date of Birth (Enter in format MM-DD-YYYY)

-

-

FVRS No: _____________________________________ If no FL DL or FL ID, then provide Last 4 digits of Social Security Number

Florida Driver’s License (FL DL) or Florida identification (FL ID) Card Number

 I have

-

-

First Name Apt/Lot/Unit Apt/Lot/Unit Apt/Lot/Unit Gender M

City City City

Middle Name or Initial County

NONE of these numbers. Name Suffix
(Jr., Sr., I, II, etc.):

Zip Code Zip Code Zip Code

State or Country State

State or Country of Birth

F

Telephone No. (optional) ( )

Race/Ethnicity (Check only one)

 Florida Democratic Party  Republican Party of Florida  No party affiliation  Minor political party (print name):
______________________

 American Indian/Alaskan Native  Asian/Pacific Islander  Black, not of Hispanic Origin  Hispanic  White, not of Hispanic Origin  Other:________________  Multi-racial
SIGN/ MARK HERE

Active Uniformed Services, Merchant Marine, or Overseas U.S. Citizen (Check only one if applicable)

 I will need assistance with voting.

 Active duty uniformed services/merchant marine  Family member of active duty uniformed services or merchant marine member

 I am interested in becoming a poll worker. Date

 U.S. Citizen Residing Outside U.S.

H

Oath: I do solemnly swear (or affirm) that I will protect and defend the Constitution of the United States and the Constitution of the State of Florida, that I am qualified to register as an elector under the Constitution and laws of the State of Florida, and that all information provided in this application is true.

Address your envelope to your County Supervisor of Elections. (updated 4/9/2012)
ALACHUA COUNTY Supervisor of Elections 111 SE 1st Ave Gainesville FL 32601 352-374-5252 BAKER COUNTY Supervisor of Elections PO Box 505 MacClenny FL 32063 904-259-6339 BAY COUNTY Supervisor of Elections 830 W. 11th St. Panama City FL 32401 850-784-6100 BRADFORD COUNTY Supervisor of Elections PO Box 58 Starke FL 32091 904-966-6266 BREVARD COUNTY Supervisor of Elections PO Box 410819 Melbourne FL 32781-0819 321-264-6740 BROWARD COUNTY Supervisor of Elections PO Box 029001 Fort Lauderdale FL 33302 954-357-7050 CALHOUN COUNTY Supervisor of Elections 20859 Central Ave. E., Room G10 Blountstown FL 32424 850-674-8568 CHARLOTTE COUNTY Supervisor of Elections 226 Taylor Street, Unit 120 Punta Gorda FL 33950 941-833-5400 CITRUS COUNTY Supervisor of Elections 120 N. Apopka Ave. Inverness FL 34450 352-341-6740 CLAY COUNTY Supervisor of Elections PO Box 337 Green Cove Springs FL 32043-0337 904-284-6350 COLLIER COUNTY Supervisor of Elections 3295 Tamiami Trail E., Rev. Dr. MLK Jr. Bldg. Naples FL 34112 239-252-8450 COLUMBIA COUNTY Supervisor of Elections 971 W. Duval St., Suite 102 Lake City FL 32055-3737 386-758-1026 DESOTO COUNTY Supervisor of Elections PO Box 89 Arcadia FL 34265 863-993-4871 DIXIE COUNTY Supervisor of Elections PO Box 2057 Cross City FL 32628 352-498-1216 DUVAL COUNTY Supervisor of Elections 105 E. Monroe St. Jacksonville FL 32202 904-630-1414 ESCAMBIA COUNTY Supervisor of Elections PO Box 12601 Pensacola FL 32591-2601 850-595-3900

FLAGLER COUNTY Supervisor of Elections PO Box 901 Bunnell FL 32110-0901 386-313-4170 FRANKLIN COUNTY Supervisor of Elections 47 Ave. F Apalachicola FL 32320 850-653-9520 GADSDEN COUNTY Supervisor of Elections PO Box 186 Quincy FL 32353 850-627-9910 GILCHRIST COUNTY Supervisor of Elections 112 S. Main St., Room 128 Trenton FL 32693 352-463-3194 GLADES COUNTY Supervisor of Elections PO Box 668 Moore Haven FL 33471 863-946-6005 GULF COUNTY Supervisor of Elections 401 Long Ave. Port St. Joe FL 32456-1707 850-229-6117 HAMILTON COUNTY Supervisor of Elections 1153 US Hwy. 41 NW, Suite 1 Jasper FL 32052 386-792-1426 HARDEE COUNTY Supervisor of Elections 311 N. 6th Ave. Wauchula FL 33873 863-773-6061 HENDRY COUNTY Supervisor of Elections PO Box 174 LaBelle FL 33975 863-675-5230 HERNANDO COUNTY Supervisor of Elections 20 N. Main St., Room 165 Brooksville FL 34601 352-754-4125 HIGHLANDS COUNTY Supervisor of Elections PO Drawer 3448 Sebring FL 33871 863-402-6655 HILLSBOROUGH COUNTY Supervisor of Elections 601 E. Kennedy Blvd., 16th Floor Tampa FL 33602 813-272-5850 HOLMES COUNTY Supervisor of Elections 201 N. Oklahoma St., Suite 102 Bonifay FL 32425 850-547-1107 INDIAN RIVER COUNTY Supervisor of Elections 4375 43rd Ave., Unit 101 Vero Beach FL 32967 772-226-3440 JACKSON COUNTY Supervisor of Elections PO Box 6046 Marianna FL 32447 850-482-9652 JEFFERSON COUNTY Supervisor of Elections 380 W. Dogwood St. Monticello FL 32344 850-997-3348 LAFAYETTE COUNTY Supervisor of Elections PO Box 76 Mayo FL 32066 386-294-1261

LAKE COUNTY Supervisor of Elections PO Box 457 Tavares FL 32778-0457 352-343-9734 LEE COUNTY Supervisor of Elections PO Box 2545 Fort Myers FL 33902 239-533-VOTE (8683) LEON COUNTY Supervisor of Elections PO Box 7357 Tallahassee FL 32314-7357 850-606-VOTE (8683) LEVY COUNTY Supervisor of Elections 421 S. Court St. Bronson FL 32621 352-486-5163 LIBERTY COUNTY Supervisor of Elections PO Box 597 Bristol FL 32321 850-643-5226 MADISON COUNTY Supervisor of Elections 229 SW Pinckney St., Room 113 Madison FL 32340 850-973-6507 MANATEE COUNTY Supervisor of Elections PO Box 1000 Bradenton FL 34206 941-741-3823 MARION COUNTY Supervisor of Elections PO Box 289 Ocala FL 34478-0289 352-620-3290 MARTIN COUNTY Supervisor of Elections PO Box 1257 Stuart FL 34995 772-288-5637 MIAMI-DADE COUNTY Supervisor of Elections PO Box 521550 Miami FL 33152-1550 305-499-VOTE (8683) MONROE COUNTY Supervisor of Elections 530 Whitehead St., Suite 101 Key West FL 33040-6577 305-292-3416 NASSAU COUNTY Supervisor of Elections 96135 Nassau Place, Suite 3 Yulee FL 32097 904-491-7500 OKALOOSA COUNTY Supervisor of Elections 302 Wilson St. N., Suite 102 Crestview FL 32536-3440 850-689-5600 OKEECHOBEE COUNTY Supervisor of Elections 304 NW 2nd St., Room 101 Okeechobee FL 34972 863-763-4014 ORANGE COUNTY Supervisor of Elections PO Box 562001 Orlando FL 32856 407-836-2070 OSCEOLA COUNTY Supervisor of Elections 2509 E. Irlo Bronson Memorial Hwy. Kissimmee FL 34744 407-742-6000 PALM BEACH COUNTY Supervisor of Elections PO Box 22309 West Palm Beach FL 33416 561-656-6200

PASCO COUNTY Supervisor of Elections PO Box 300 Dade City FL 33526-0300 352-521-4302 PINELLAS COUNTY Supervisor of Elections 13001 Starkey Road Largo FL 33773-1416 727-464-6788 POLK COUNTY Supervisor of Elections PO Box 1460 Bartow FL 33831-1460 863-534-5888 PUTNAM COUNTY Supervisor of Elections 2509 Crill Ave., Suite 900 Palatka FL 32177 386-329-0224 SANTA ROSA COUNTY Supervisor of Elections 6495 Caroline St., Suite F Milton FL 32570-4592 850-983-1900 SARASOTA COUNTY Supervisor of Elections PO Box 4194 Sarasota FL 34230-4194 941-861-8600 SEMINOLE COUNTY Supervisor of Elections PO Box 1479 Sanford FL 32772-1479 407-585-VOTE (8683) ST. JOHNS COUNTY Supervisor of Elections 4455 Ave. A, Suite 101 St. Augustine FL 32095 904-823-2238 ST. LUCIE COUNTY Supervisor of Elections 4132 Okeechobee Road Fort Pierce FL 34947 772-462-1500 SUMTER COUNTY Supervisor of Elections 900 N. Main St. Bushnell FL 33513 352-569-1540 SUWANNEE COUNTY Supervisor of Elections 220 Pine Ave. SW Live Oak FL 32064 386-362-2616 TAYLOR COUNTY Supervisor of Elections PO Box 1060 Perry FL 32348 850-838-3515 UNION COUNTY Supervisor of Elections 175 W. Main St. Lake Butler FL 32054 386-496-2236 VOLUSIA COUNTY Supervisor of Elections 125 W. New York Ave. DeLand FL 32720-4208 386-736-5930 WAKULLA COUNTY Supervisor of Elections PO Box 305 Crawfordville FL 32326-0305 850-926-7575 WALTON COUNTY Supervisor of Elections 571 E. Nelson Ave. (US Hwy. 90) DeFuniak Springs FL 32433 850-892-8112 WASHINGTON COUNTY Supervisor of Elections 1331 South Blvd., Suite 900 Chipley FL 32428 850-638-6230

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