4 Bengali Form

National Voter Registration Act (NVRA) Regulations for Voter Registration Application

Federal_Voter_Registration_BEN

Voter Registration Application

OMB: 3265-0015

Document [pdf]
Download: pdf | pdf
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Before completing this form, review the General, Application, and State specific instructions.

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lfyou check '"No" in response to either of these questions, do not complete form.
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Last Name/�

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AptorLot#/��a!>#

Address Where You Get Your Mail If Different From Above/�91Glif����9R'a��C! =���el!"l"i'!/f.ifiw-ffl (<[:
■ l am a United States citizen./ ""11>!� "1-'ll'ffirl'
■ I meet the eligibility requirements of my state and subscribe to any oath required./ i?if@r � � i?if@r
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■ The information I have provided is true to the best of my knowledge under penalty of perjury. lfl have provided false information, I may be fined, imprisoned, or (if not a U.S. citizen) deported from or refused entry
to the United States. /"l"i'l'51:'RPTT:�lf�""1i>!(<[>rt>'11!l"1)��(>11,]"1fl!B!-..flo>!KiPl'3Jl ""11>1-.ffet
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ID Number (See Item 6 in the instructions for your state)/
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Please sign 1\,11 name (or put mark)/'>i'I$ltG"jrn'll"l�¥-!(slwe,fiR)
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are registering to vote for the first time: please refer to the application instructions for information on submitting copies of valid identification documents with this form.

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app1·Icauon .IS f◄or achan2e of name, w 1at was your name bef◄ore you chang,ed.?/
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Last Name/�

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First Name/�� '5l"�"l'f �

Middle Name(s)/ 'l'IJ'll"l(�Foi)

If you were registered before but this is the first time you are registering from the address in Box 2, what was your address where you were registered be fore?

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If the applicant is unable to sign, who helped the applicant fill out this application? Give name, address and phone number (phone number optional).

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&C&� � 0l t� I �C�C� C>t&IC� I!!� �IClil som:'lf.mtRi(��iSMJ �$'!'GI��� ""1'TI) �A>'l1w-l�"I-�! 1 2 4 7 o (Circle one)/("1�011o!'!l'lfii.l) LastName/9'l1'R Mr./ Mrs./ Miss/ FirstName/� �i!i{�� Ms./ This space for office use only./ "l�����iSMJI o (Circle one)/(�011o!'!l'lfii.l} MiddleName(s) / 'l'O"-TT'l(Sfiar} \'JJRllil � � � � m'!lil II Ill IV Apt. orLot#/�'lt"W# City/Town I "ITT� State/� Zip Code/ �91 � Address Where You Get Your Mail If Different From Above/ ltlr:I c>n:'l'FSll'! Day/� Year/ !�- (st 1%,;;, fif.l) The information I ha,·e provided is true to the best of my knowledge under penalty of perjury. If I have pro,·ided false information, I may be fined, imprisoned, or (if not a U.S. citizen) deported from or refused entry to the VnitedStates./"l"l'!='il:�H"l�"llfiic,r'fll'IJi \ Day/� \ Year/� I Ifyou are registering to vote for the first time: please refer to the application instructions for infonnation on submitting copies of valid identification documents with this fonn. m91R� Clf'GWfiSRJ' ('flS!!Bf���ci1fu.'l-1 B Apt or Lot#/ �<11 Street (or route and box number)/ �(��<3 �'fflil) City/Town/County I "ITT�� State/� (.��f� Zip Code/ �91 � Ifyou live in a rural area but do not have a street number, or ifyou have no address, please show on the map where you live. m91f.f 1c-TT �� -rt ', 1c-TT �-rt ' � �� Cll" m91f.f � � � � � � ■ ■ ■ C Write in the names of the crossroads (or streets) nearest to where you live./������� (;jf'f ���I NORTH/�� Draw an X to show where you live. 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    File Typeapplication/pdf
    File TitleFederal Voter Registration_3-15-22_BEN
    File Modified2023-04-12
    File Created2023-02-03

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