SOS Approved 7/2/08
C.R.S. 1-8-104, 1-8-104.5, and 1-8-105
Colorado – Combination Voter Registration & Mail-In Ballot Application
Instructions:
• PRINT clearly using black ink
• READ the important information on the reverse side
• SIGN and mail, fax, or email this form as a PDF to your County Clerk
For County Clerk and Recorder Use Only
VOTER INFORMATION: Required fields must be completed.
Are you a citizen of the United States? (Required)
YES
NO
If you checked “NO” to this question, DO NOT COMPLETE THIS FORM.
Will you be 18 years of age on or before Election Day? (Required)
YES
NO
If you checked “NO” to this question, DO NOT COMPLETE THIS FORM.
Last Name (Required)
First Name (Required)
Middle Name
Suffix (Jr., III)
Previous Name of Applicant (If Applicable)
Colorado Legal Residence Street Address (Required – No P.O. Boxes)
Apt/Unit #
City/Town (Required)
Zip (Required)
County
Mailing Address or P.O. Box (Required if different from address above)
Apt/Unit #
City/Town (Required)
State (Required)
Zip (Required)
Date of Birth (Required)
/ /
MM
DD
YYYY
Gender (Required)
Male
Female
Telephone Number
(Including Area Code)
( )
Party Affiliation – Select Only One
(Required to vote in that party’s Primary Election)
Democratic
Republican
American Constitution
Green
Libertarian
Unity
Unaffiliated
IDENTIFICATION (Required)
DO NOT LEAVE THIS SECTION BLANK
Pursuant to Federal Law, your completed voter registration form must contain your
State of Colorado Driver's License Number or your Dept. of Revenue Identification
Number. If you do not have a Driver’s License or Dept. of Revenue Identification
Number, then you must provide the last four digits of your Social Security Number.
If you do not have a Driver’s License Number, a Dept. of Revenue Identification
Number, or a Social Security Numb