Kentucky Voter Registration CardKentucky Voter Registration Card
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SBE 01 (08/03)

You MUST answer questions A & B below before completing this form.
4069001
YES
NO If you checked “no” in response to either of
YES
NO these questions, do not complete this form.

A. Are you a citizen of the United States of America?
B. Will you be 18 years of age on or before election day?
Check one:
New
Registration

FOR CLERK USE ONLY
Address
Change

Party
Name
Change
Change
Social Security Number

PRECINCT CODE

Date of Birth (M-D-Y)
Last Name

Female

PRECINCT NAME

County (where you live)
First Name

TOWN

Work Phone

Middle Name

OTHER
CODE

Home Phone
Suffix (circle one)
Jr. Sr. II III IV

Male

Address where you live (do not give PO Box address):

Apt #

City

Zip Code

Address where you get your mail
(if different from above):

Apt #

City

Zip Code

Party Registration – check one box
Democratic Party
Republican Party
Other _______________________________
(write name above)

If you select “Other” as your party affiliation, you are
eligible to vote for only nonp