Arkansas Voter Registration Application

NAME

Address Where you live (See section "C" below)

Rural address must complete map

Date Of Birth

Home and Work Phone Number (Optional)

If you answered No in response to either questions A or B, do not complete this form.

If you answered Yes in response to either questions C or D, do not complete this form.

The information I have provided is true to the best of my knowledge. I do not claim the right to vote in another county or state. If I have provided false information, I may be subject to a fine of up to $10,000 and/or imprisonment of up to 10 years un der state and federal laws.