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as of 03/10/15
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Illinois Voter Registration Application
This screen creates a PDF Form with your input so you can print and mail it into the office.
Please answer below questions and complete sections 1-10.
Once complete, click the "Submit" button at the bottom to create and view the PDF form.
Print and sign the PDF form before mailing it to the County Clerk's Office.
If you just want to print a blank form,
Are you a citizen of the United States of America?
Will you be 18 years of age on or before
OR are you currently 17 and will be 18 by the day of the next General Election
If you check "no" in response to either of these questions, do not complete this form.
Check applicable box:
Apply to register to vote in Illinois
Change your address
Change your name
1. Last Name
Middle Name or Initial
Suffix (Select one)
2. Address where you live: (House No., Street Name, Apt. No.)
3. Mailing address: (Post Office Box)
4. Former Registration Address: (include City, State and Zip Code)
5. Former Name (If changed)
6. Date of Birth: MM/DD/YY
7. Sex: (select one)
8. Daytime telephone number
including area code:
9. ID number – check the applicable box
and provide the appropriate ID# below
IL Driver’s License or, if none, IL Secretary of State ID or
Last 4 digits of Social Security Number
I have none of the identification numbers listed above
10. Voter Affidavit – Read all statements and sign within the box to the right.
I swear or affirm that:
I am a citizen of the United States;
I will be at least 18 years old on or before the next election
(or the next General Election)
I will have lived in the State of Illinois and in my election precinct at least 30 days as of the date of the next election;
The information I have provided is true to the best of my knowledge under penalty of perjury. If I have provided false information, then I may be fined, imprisoned, or if I am not a U.S. citizen, deported from or refused entry into the United States.
11. If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.
Name of person assisting.
Click the SUBMIT button to create and view the PDF Form.