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Ast 18 years of age on or before election day? Last Name (Required) First Name (Required) M M D D Y Y Middle Name (Required) Y Y Jr III Date of Birth MMDDYYYY (Required) If you know your NC Voter Registration Number, please enter it here: 3 Yes No Are you at least 16 years of age and understand that you must Yes No be 18 years of age on or before election day to vote? IF YOU CHECKED "NO" IN RESPONSE TO BOTH OF THESE QUESTIONS ABOVE, DO NOT SUBMIT THIS FORM. IF YOU CHECKED "NO" IN.

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