Commonwealth of
Virginia
NVCC
125-3
Northern Virginia Community
College
Voter Registration Agency Verification
8/00
If you are not registered to vote where you live now, would you like to apply to register to vote today?
(Please
check one) q I am already registered to vote at
my current address, or I am not eligible to register to vote and do not
need an application to register to vote. q Yes, I would like to apply to
register to vote (please fill out
the voter registration application form). q No, I do not want to register to
vote.
If
you do not check a box, you will be considered to have decided not to register
to vote at this time. Applying to
register to vote or declining to register to vote will not affect the
assistance or services that you will be provided by this agency.
If
you decline to register to vote, this fact will remain confidential. If you do register to vote, the office where
your application was submitted will keep it confidential, and will be used only
for voter register purposes.
If
you would like help filling out the voter registration application form, we
will help you. The decision whether to
seek or accept help is yours. You may
fill out the application form in private if you desire.
If you believe
that someone has interfered with your right to register or to decline to
register to vote, your privacy in deciding whether to register or in applying
to register to vote, you may file a complaint with:
Secretary
of the Virginia State Board of Elections
Ninth Street Office Building
200 North Ninth Street Room 101
Richmond, VA 23219-3497
804-786-6551
________________________ _____________________ ______________
Applicant Name (Please print) Signature Date
---------------------------------For Office Use Only--------------------------------
Voter Registration Form completed: ¨ Yes ¨ No
Voter
Registration form given to applicant for later mailing (at applicant’s request) ¨
_
NVCC Staff Signature Date