Rhode Island Voter Registration Form X

Eligibility

If you check “No” in response

to any of these questions, do not

complete this form.

Personal Information

All elds on this form are required

except when indicated as optional.

Phone/email is optional and is

public record.

Identication Numbers

If you have never voted in

Rhode Island, please enter the

appropriate identication number.

Driver’s License and State ID card

must be issued by the

RI Division of Motor Vehicles.

You may also submit a copy of

your identication with this

application.

Rhode Island

Home Address

Mailing Address

If dierent from

Rhode Island Home Address.

Party Aliation

Armation

and Signature

Update my Information

If you have changed your name or

were already registered to vote in

RI or in another state.

Get Involved!

Last Name Sux

First Name Middle Initial

Date of Birth (mm/dd/yyyy) Phone/Email (optional)

Previous Name

Previous Address (County, City/Town, State, Zip Code)

I am interested in being a poll worker

I swear or arm that:

I am a U.S. Citizen; I live at the address set forth above; I will be at least eighteen (18) years old

when I vote; I am not incarcerated in a correctional facility upon a felony conviction; I have not

been lawfully judged “mentally incompetent” to vote by a court of law. The information I have

provided is true to the best of my knowledge under pains and penalty of perjury. If I have provided

false information, I may be ned, imprisoned, or (if not a U.S. citizen) deported from or refused

entry into the United States.

SIGN HERE:

Rhode Island

Voter Registration Form

This form is for: New voter Update my information Party change

Are you a citizen of the United States? Yes No

Are you a resident of Rhode Island? Yes No

Are you at least 16 years of age? Yes No

Home Address (Not a PO Box) Unit Number

City/Town State Zip Code

Democrat Republican Unaliated Other: ___________________

Rhode Island Driver’s License or State ID card number:

__________________________

I have not been issued a RI Driver’s License or State ID card.

Enter the last 4 digits of your Social Security Number (SSN): ______ ______ ______ ______

I have not been issued a RI Driver’s License, State ID card, or a Social Security Number.

You must be 18 years old to vote.

Mailing Address Unit Number

City/Town State Zip Code

Ocial use for barcode

Date Signed

(mm/dd/yyyy)

Warning: If you sign this

form and know it to be false,

you can be convicted and

ned up to $5,000 or jailed

up to 10 years.

Barrington Town Hall

283 County Rd. 02806

247-1900 x4

Bristol Town Hall

10 Court St. 02809

253-7000

Burrillville Town Hall

105 Harrisville Main St.

Harrisville 02830

568-4300

Central Falls City Hall

580 Broad St. 02863

727-7450

Charlestown Town Hall

4540 South County Trl. 02813

364-1200

Coventry Town Hall

1670 Flat River Rd. 02816

822-9150

Cranston City Hall

869 Park Ave. 02910

780-3126

Cumberland Town Hall

45 Broad St. 02864

728-2400

East Greenwich Town Hall

125 Main St.,

P.O. Box 111 02818

886-8603

East Providence City Hall

145 Taunton Ave. 02914

435-7502

Exeter Town Hall

675 Ten Rod Rd. 02822

294-2287

Foster Town Hall

181 Howard Hill Rd. 02825

392-9201

Glocester Town Hall

1145 Putnam Pike

P.O. Box B, Chepachet 02814

568-6206 x0

Hopkinton Town Hall

1 Town House Rd. 02833

377-7777

Jamestown Town Hall

93 Narragansett Ave. 02835

423-9804

Johnston Town Hall

1385 Hartford Ave. 02919

553-8856

Lincoln Town Hall

100 Old River Rd.

P.O. Box 100 02865

333-1140

Little Compton Town Hall

40 Commons

P.O. Box 226 02837

635-4400

Middletown Town Hall

350 East Main Rd. 02842

849-5540

Narragansett Town Hall

25 Fifth Ave. 02882

782-0625

Newport City Hall

43 Broadway 02840

845-5386

New Shoreham Town Hall

16 Old Town Rd.

P.O. Box 220 02807

466-3200

North Kingstown Town Hall

100 Fairway Dr, 02852

294-3331 x128

North Providence Town Hall

2000 Smith St. 02911

232-0900 x234

North Smitheld

Municipal Annex

575 Smitheld Rd. 02896

767-2200

Pawtucket City Hall

137 Roosevelt Ave. 02860

722-1637

Portsmouth Town Hall

2200 East Main Rd. 02871

683-3157

Providence City Hall

25 Dorrance St. 02903

Room 102

421-0495

Richmond Town Hall

5 Richmond Townhouse Rd.

Wyoming 02898

539-9000 x9

Scituate Town Hall

195 Danielson Pike

P.O. Box 328

North Scituate 02857

647-7466

Smitheld Town Hall

64 Farnum Pike, 02917

233-1000 x116

South Kingstown Town Hall

180 High St.

Wakeeld 02879

789-9331 x1231

Tiverton Town Hall

343 Highland Rd. 02878

625-6703

Warren Town Hall

514 Main St. 02885

245-7340

Warwick City Hall

3275 Post Rd. 02886

738-2010

West Greenwich Town Hall

280 Victory Hwy. 02817

392-3800

West Warwick Town Hall

1170 Main St. West Warwick, RI

02893

822-9201

Westerly Town Hall

45 Broad St. Westerly, RI 02891

348-2503

Woonsocket City Hall

169 Main St.

P.O. Box B 02895

767-9221

Return Address

__________________________________________

Mail to: BOARD OF CANVASSERS

____________________________________________

Postage

Required

Post Oce

will not deliver

without proper

postage.