For a copy of the on-line PDF version of the Louisiana Mail Voter Registration Application Form 110, click here. To view and print a PDF file, you must have the Adobe Acrobat Reader installed on PC. To obtain a free copy, visit Adobe’s website.

YOU CAN USE THIS FORM TO:

1. Register to vote
2. Change your address
3. Request a name change
4. Change party affiliation

TO REGISTER YOU MUST:

1. be a United States citizen
2. be at least 17 years old to register but must be 18 years old to vote
3. not be under an order of imprisonment for conviction of a felony
4. not be under a judgment of full interdiction or limited interdiction where your right to vote has been suspended
5. reside in the state and parish in which you seek to register and vote

INSTRUCTIONS FOR COMPLETING THIS FORM:

All information except your signature should be printed clearly in ink, preferably black, or typed. Fill in all boxes that apply to you.

Box 1: Indicate whether you are a citizen of the United States of America. Indicate whether you will be 18 years of age on or before election day.

Box 2: Provide full name. Do not use initials for middle or maiden name.

Box 3: ‘Residence Address’ means the address where you live and are registering to vote. If you claim a homestead exemption, you must list the address of that residence. Do not use a post office box for your ‘Residence Address’. If you use a rural route and box number, draw a map in the space labeled ‘Give Location.’ Write in the names of the crossroads (streets) nearest to where you live. Draw an X to show where you live. Use a dot to show any schools, churches, stores or landmarks near where you live and write the name of the landmark. Complete ‘Mailing Address’ only if it is different from the ‘Residence Address’.

Box 4: Provide your age.

Box 6 & 16: You must provide your Louisiana driver’s license number, if issued. If not issued, you must provide at least the last four digits of your social security number, if issued. The full social security number may be provided on a voluntary basis. If neither a social security number nor a Louisiana driver’s license number has been issued, and this form is submitted by mail, and you are registering to vote for the first time, in order to avoid additional identification requirements for first time voters, attach either a) a copy of a current and valid photo identification or b) a copy of a current utility bill, bank statement, government check, paycheck, or other government document that shows your name and address.

Boxes 8, 11 & 12: The items “race/ethnic origin”, “daytime phone” and “home phone” are not required but are helpful.

Box 9: If you do not complete this item, your party affiliation will be listed as ‘none’;. If you are not affiliated with a political party, please circle ‘none’. The recognized political parties are Democrat, Republican, Libertarian, Green and Reform or you may specify any other party affiliation.

Box 17: If you are using this form to request a change of name, you must print the name to be changed here.

Box 19: Date and sign the card with your signature or mark.

If returned by mail, place in an envelope, using the address of the appropriate Registrar of Voters found on the reverse side of the form. If you have not been issued a social security number or Louisiana driver’s license number, you must mail it in an envelope so that you can include the required documentation with your application. Your application or envelope must be postmarked 30 days prior to the first election in which you seek to vote based on the residence listed on this application.

NOTE: 1. If you decline to register to vote, this fact will remain confidential and will be used only for voter registration purposes. If you register to vote, the office where your application was submitted will remain confidential and will be used only for voter registration purposes. 2. Your social security number will also remain confidential and is intended to be used for voter registration purposes only.

Faxed Voter Registration forms are not accepted. The Voter Registration form should be addressed and mailed or hand-delivered to the appropriate Registrar of Voters in the parish in which you are registering.

Do not mail or otherwise send Voter Registration forms to the Secretary of State Elections Division office. Deadlines requiring receipt in the registrar’s office may be missed.

More Questions?
Call your Parish Registrar of Voters OR call the Department of State at 1-800-825-3805 or (225) 922-0900.

Be sure to complete and check all applicable boxes.

For a copy of the on-line PDF version of the Louisiana Mail Voter Registration Application Form 110, click here.

*form instructions courtesy of presidentialelection.com