NEW YORK STATE MOTOR VOTER REGISTRATION APPLICATION

Instructions: You must sign this application where indicated. This information is being collected for the New York State Board of Elections. Please mail this form to your local board of elections at the address below. Providing updated information on this form does not change information on your DMV records. Your County Board of Elections will notify you when your application has been processed. If you do not receive confirmation from them you should contact them directly.

If you believe that someone has:

Interfered with your right to register or decline to register to vote, Your right to privacy in deciding whether to register or in applying to register to vote, Or your right to choose your own political party or other political preference,

You may file a complaint with: The NYS Board of Elections 40 Steuben Street Albany, NY 12207-2109 Phone: 1-800-469-6872 If you have any questions about registering to vote: Call your County Board of Elections or call 1-800-FOR-VOTE (1-800-367-8683) (This number is only for voter registration questions.) If you live in New York City, you should call 1-212-VOTE-NYC. (1-212-868-3692) Hearing impaired people with TDD may call 1-800-533-8683. Please mail the completed and signed Voter Registration application to the following address: Albany County Board of Elections 32 North Russell Rd Albany, NY 12206 522128383 Check Boxes That Apply: New registration and enrollment Party enrollment change First Name
EUGENE

Are you a U.S. Citizen? Yes X

No

For Board Use Only Address change X Name change Middle Initial
R

If you answered NO, do not complete this form. Last Name

LABARGE

Suffix

Address Where You Live (do not give P.O. Address)

51 COHOES RD

Apt. No.
2

City/Town/Village
WATERVLIET

Zip Code
12189

County
ALBANY

Address Where You Get Your Mail (If different from above) Date of Birth
04/29/1963

P.O. Box, Star Rte., etc.

Post Office

Zip Code

Sex Female

Home Telephone Number (optional) Male X In County/State

ALBANY, NY

Last Year You Voted

2008

Your address was (Give house number, street, and city) 240 5TH AVE TROY

Under Name (If different from your name now)

Choose a Party Check one box only Please Note: In order to vote in a primary election, you must be enrolled in a party. Republican Party Democratic Party Independence Party
X Conservative Party

Affidavit: I swear or affirm that I am a citizen of the United States. I will have lived in the county, city, or village for at least 30 days before the election. This is my signature on the line below. The above information is true. I understand that if it is not true I can be convicted and fined up to $5,000 and/or jailed for up to four years. Signature or Mark

Liberal Party Right to Life Party Green Party Working Families Party I do not wish to enroll in a party

Date