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HALL COUNTY NEBRASKA VOTER REGISTRATION FORM I am at least eighteen years of age or will be eighteen years of age on or before the first Tuesday after the first Monday of November. IMPORTANT Any registrant who signs this application knowing that any of the information on the application is false shall be guilty of a Class IV felony under section 32-1502 of the statutes of Nebraska. The penalty for such is up to 5 years imprisonment a fine of up to 10 000. 00 or both. Signature of Voter Date You can fill most of this form in electronically print it out sign it and then FAX it back to us at 308-385-5071 or mail it to us at Hall County Election Commissioner 121 South Pine Street Grand Island NE 68801 If you can t see the areas in which you can enter data on this form electronically in try selecting the Edit Menu - Preferences and then click on the checkbox next to Show background and hover color for form fields. If you still can t see the fields print out the form and fill it out by hand. Note that the following fields for the Voter Registration form are required 1. Note if you wish to vote in both partisan and nonpartisan primary elections you must indicate a political party affiliation on the registration form. If you register without a political party affiliation Nonpartisan you will receive only the nonpartisan ballots at a primary election. Democrat Republican Libertarian Nonpartisan To the best of my knowledge and belief I declare under penalty of election falsification that I live in the State of Nebraska at the address provided in this application. I have not been convicted of a felony or if convicted it has been at least two years since I completed my sentence for the felony including any parole term I have not been officially found to be non compos mentis mentally incompetent and I am a citizen of the United States. IMPORTANT Any registrant who signs this application knowing that any of the information on the application is false shall be guilty of a Class IV felony under section 32-1502 of the statutes of Nebraska. The penalty for such is up to 5 years imprisonment a fine of up to 10 000. 00 or both. Signature of Voter Date You can fill most of this form in electronically print it out sign it and then FAX it back to us at 308-385-5071 or mail it to us at Hall County Election Commissioner 121 South Pine Street Grand Island NE 68801 If you can t see the areas in which you can enter data on this form electronically in try selecting the Edit Menu - Preferences and then click on the checkbox next to Show background and hover color for form fields. Yes No I am a citizen of the United States. Yes No If you checked NO in response to either of the questions above do not complete this application* Gender M Last Name First Name Middle Initial Residence Address Street Number and Name City Nebraska Drivers Lic or Last four digits of SS Suffix Postal Address if different than residence Date of Birth Month/ Day / Year Birthplace State Previously Registered Name Maiden Name State NE Zip Code Phone Number Political Party Affiliation Check One.

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