Form SOS-VR Application for Addition to the Checklist (Voter Registration Form) - Vermont

Form SOS-VR or the "Application For Addition To The Checklist (voter Registration Form)" is a form issued by the Vermont Secretary of State.

Download a PDF version of the Form SOS-VR down below or find it on the Vermont Secretary of State Forms website.

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VERMONT Application for Addition to the Checklist (VOTER REGISTRATION FORM)
17 V.S.A. § 2145
(Please print clearly, use ballpoint pen, and bear down hard.)
I, ______________________________________________________________
apply to have my name
)
(Last Name)
(First Name)
(Middle Initial
added to the checklist of the Town/City of ______________________________________.
By checking the boxes below, I swear or affirm that these are true statements:
 Yes
 No Are you a citizen of the United States?
 Yes
 No Will you be eighteen years of age or older on or before the day of election?
 Yes
 No Are you a resident of Vermont?
If you cannot check "Yes" in response to all three questions above, DO NOT complete this form. You are not qualified
to vote in Vermont
. Contact the Office of the Secretary of State, Elections Division, for more information at (800) 439-8683.
I was born on ________________________ at _________________________________, ___________________________
(Date)
(Town or City)
(State)
My principal dwelling place is located at:_________________________________________________________________
(E911 street address including number or exact physical location, if no E911 address)
Mailing Address: ___________________________________________________________ Tel. #: ___________________
Email:__________________________________________
(optional - for contact purposes only).
By registering to vote in the above named town in Vermont, I authorize my name to be removed from the list of registered voters in any
previous place where I was registered to vote.
The last address I was registered to vote at: __________________________________________________________.
(Physical location – include number, street, town, state and zip code)
I was previously registered with a different last name of: _______________________________________________________.
My VT Driver’s License or Personal I.D. # (PID#) issued by VT DMV is__________________.
This # is REQUIRED.
IF you do not have a VT Driver’s License or PID# issued by VT DMV enter the last 4 digits of your Social Security
Number:________ . If you do not have a VT PID#, or SSN, please contact the Office of the Secretary of State, Elections Division,
(800)439-8683.
First time Registrants in VT must take the voter’s oath. The oath may be self-administered. You must be 18 to take the oath:
“You solemnly swear or affirm that whenever you give your vote or
VOTER'S OATH (Vermont Constitution, Chapter II, Section 42):
suffrage, touching any matter that concerns the State of Vermont, you will do it so as in your conscience you shall judge will
most conduce to the best good of the same, as established by the Constitution, without fear or favor of any person.”
By checking this box I swear or affirm that:
I have taken the Voter's Oath
I meet all of the eligibility requirements to vote in this municipality
. I hereby swear, or affirm, under penalty of perjury
and other potential federal or state criminal penalties of up to a $10,000 fine, or imprisonment for not more than fifteen years, or
both, that the statements made by me in this application are true
. (17 V.S.A. § 2145(f); 17 V.S.A. § 2011; 42 U.S.C. § 1973gg-10).
____________________________
______________________________________________
Today’s Date
Applicant’s Signature
st
if you are registering to vote for the 1
time in Vermont, AND you are mailing this application to your town clerk
ONLY
individually, you must submit a photocopy of one of the following: current & valid photo identification OR bank statement, utility bill,
or government document with your name and current address. (Do not submit I.D. if you have been previously registered in VT, if
this form is submitted as part of a voter registration drive, or if you return this form to the clerk’s office in person.)
FOR OFFICIAL USE:  The Town Clerk OR the BCA has reviewed the application AND the applicant  was added to the
checklist. The applicant’s usual polling place is: _____________________________________________. OR the applicant  was
rejected and NOT added to the checklist. The reason(s) for rejection are: _____________________________________.
Signature of town clerk: ____________________________.
Date Entered on Checklist: _____________ Date Notification Sent to Voter:_____________ Date Approved: ____________
. Contact your Town Clerk to make sure your application has been received.
KEEP THE PINK COPY OF THIS APPLICATION FORM
Bring pink copy to the polls when you go to vote. This is proof you have submitted an application before the deadline for registration.
[SOS-VR-11/21/2017]
VERMONT Application for Addition to the Checklist (VOTER REGISTRATION FORM)
17 V.S.A. § 2145
(Please print clearly, use ballpoint pen, and bear down hard.)
I, ______________________________________________________________
apply to have my name
)
(Last Name)
(First Name)
(Middle Initial
added to the checklist of the Town/City of ______________________________________.
By checking the boxes below, I swear or affirm that these are true statements:
 Yes
 No Are you a citizen of the United States?
 Yes
 No Will you be eighteen years of age or older on or before the day of election?
 Yes
 No Are you a resident of Vermont?
If you cannot check "Yes" in response to all three questions above, DO NOT complete this form. You are not qualified
to vote in Vermont
. Contact the Office of the Secretary of State, Elections Division, for more information at (800) 439-8683.
I was born on ________________________ at _________________________________, ___________________________
(Date)
(Town or City)
(State)
My principal dwelling place is located at:_________________________________________________________________
(E911 street address including number or exact physical location, if no E911 address)
Mailing Address: ___________________________________________________________ Tel. #: ___________________
Email:__________________________________________
(optional - for contact purposes only).
By registering to vote in the above named town in Vermont, I authorize my name to be removed from the list of registered voters in any
previous place where I was registered to vote.
The last address I was registered to vote at: __________________________________________________________.
(Physical location – include number, street, town, state and zip code)
I was previously registered with a different last name of: _______________________________________________________.
My VT Driver’s License or Personal I.D. # (PID#) issued by VT DMV is__________________.
This # is REQUIRED.
IF you do not have a VT Driver’s License or PID# issued by VT DMV enter the last 4 digits of your Social Security
Number:________ . If you do not have a VT PID#, or SSN, please contact the Office of the Secretary of State, Elections Division,
(800)439-8683.
First time Registrants in VT must take the voter’s oath. The oath may be self-administered. You must be 18 to take the oath:
“You solemnly swear or affirm that whenever you give your vote or
VOTER'S OATH (Vermont Constitution, Chapter II, Section 42):
suffrage, touching any matter that concerns the State of Vermont, you will do it so as in your conscience you shall judge will
most conduce to the best good of the same, as established by the Constitution, without fear or favor of any person.”
By checking this box I swear or affirm that:
I have taken the Voter's Oath
I meet all of the eligibility requirements to vote in this municipality
. I hereby swear, or affirm, under penalty of perjury
and other potential federal or state criminal penalties of up to a $10,000 fine, or imprisonment for not more than fifteen years, or
both, that the statements made by me in this application are true
. (17 V.S.A. § 2145(f); 17 V.S.A. § 2011; 42 U.S.C. § 1973gg-10).
____________________________
______________________________________________
Today’s Date
Applicant’s Signature
st
if you are registering to vote for the 1
time in Vermont, AND you are mailing this application to your town clerk
ONLY
individually, you must submit a photocopy of one of the following: current & valid photo identification OR bank statement, utility bill,
or government document with your name and current address. (Do not submit I.D. if you have been previously registered in VT, if
this form is submitted as part of a voter registration drive, or if you return this form to the clerk’s office in person.)
FOR OFFICIAL USE:  The Town Clerk OR the BCA has reviewed the application AND the applicant  was added to the
checklist. The applicant’s usual polling place is: _____________________________________________. OR the applicant  was
rejected and NOT added to the checklist. The reason(s) for rejection are: _____________________________________.
Signature of town clerk: ____________________________.
Date Entered on Checklist: _____________ Date Notification Sent to Voter:_____________ Date Approved: ____________
. Contact your Town Clerk to make sure your application has been received.
KEEP THE PINK COPY OF THIS APPLICATION FORM
Bring pink copy to the polls when you go to vote. This is proof you have submitted an application before the deadline for registration.
[SOS-VR-11/21/2017]
VERMONT VOTER REGISTRATION INFORMATION
(HOW TO COMPLETE the Vermont APPLICATION FOR ADDITION TO THE CHECKLIST)
To be eligible to vote in Vermont you must:
(Eligibility requirements are in 17 V.S.A. § 2121, 2122)
1. be a citizen of the United States;
2. be a resident of Vermont and a resident of the town in which you apply to be added to the checklist; (OR be a
military or overseas voter qualified under the federal Uniformed and Overseas Citizens Absentee Voting Act whose
last place of residence in the United States immediately prior to moving overseas was in a Vermont town or city);
3. take, or have previously taken, the Voter's Oath; and
4. be 18 years of age or older or will be 18 on or before the day of election.
APPLICANTS MUST REGISTER TO VOTE IN THE TOWN OR CITY WHERE THEY CURRENTLY RESIDE.
st
If you are registering to vote for the 1
time in Vermont, and you are mailing this application to your town
clerk individually, you must also submit a photocopy of one of the following forms of identification: current
& valid photo identification or bank statement, utility bill, or government document that contains your
name/current address. NO photocopy of ID is required when a person registers through a state agency or
through a voter registration drive.
You must include your Vermont DMV-issued Driver’s License Number or Personal I.D. Number (VT PID#) on the
voter application. If you do not have a Driver’s License or VT PID# issued by DMV, then you must include the last four (4)
digits of your Social Security Number. (SSN). If you do not have either, please contact the Office of the Secretary of State.
Providing your e-mail address is optional, but provides the easiest way for the Clerk to contact you.
Where to File: Keep the pink copy, and submit the top two sheets (the white and canary copies) of the form to the Town or
City Clerk in the town or city in which you reside. Clerk addresses can be found on the Secretary of State’s web site,
http://www.sec.state.vt.us, or call your town clerk, or call the Elections Division at (802) 828-2363 or (800) 439-8683. You
may also register to vote online at: https://olvr.sec.state.vt.us/. YOU MUST REGISTER TO VOTE IN THE TOWN OR CITY
WHERE YOU CURRENTLY RESIDE.
When to File: Applications may be submitted to the clerk during all normal business hours. You may also submit the
completed voter registration application to the clerk at the polling place on Election Day. Online voter registrations are
sent to the clerk immediately.
Getting on the Voter Checklist: You are not automatically registered to vote by filing this application. If the Town Clerk or
the Board of Civil Authority finds that you meet the eligibility requirements you will be added to the checklist. You will be
notified in writing whether or not your application has been approved. If you have not received notification, call your town
clerk. If you are not eligible, the Board must state the reason in writing and give you a chance to be reconsidered. If you are
still denied, you can appeal in writing to the superior court in your county. (No filing fee or lawyer is required.)
Voter’s Oath: If you have previously registered in Vermont, do not take the voter’s oath again. If not, the oath can be
administered by yourself or by any person over the age of 18. If you do not take oaths you may take it as an affirmation.
SERIOUS PENALTIES FOR FALSE INFORMATION ON AN APPLICATION TO THE CHECKLIST
It is unlawful to give false information concerning your qualifications to be a registered voter of a town or city
in Vermont. The penalties are serious, including penalties of up to a $10,000 fine or imprisonment for not more
than fifteen years, or both.
Note to Town and City Clerks:
The applicant retains the pink copy when the application is completed. After the Town
Clerk or BCA takes action, complete the bottom of the application form and mail a copy to the applicant.
The laws relating to voter registration are in 17 V. S. A. §§2121-2150. If you have questions, call your town clerk
or call the Elections Division, Office of the Secretary of State at (802) 828-2363, or (in Vermont) (800) 439-8683.
Note: If you were provided with this application form by a voter registration agency, you may decline to register. If you decline to register,
your failure to register will remain confidential and will be used for voter registration purposes. If you are submitting this application through
a voter registration agency, the office through which you submitted this application will remain confidential and will be used only for voter
registration purposes.

Download Form SOS-VR Application for Addition to the Checklist (Voter Registration Form) - Vermont

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