[ 211 ] Civics and Government GED ® TEST SOCIAL STUDIES FLASH REVIEW _____________ • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Use the form to answer the following two questions. Voter Registration Application For U.S. Citizens You can use this form to: register to vote report that your name or address has changed register with a party Please print in blue or black ink This space for office use only. 1 Mr. Mrs. Miss Ms. Last Name First Name Middle Name(s) (Circle one) Jr Sr II III IV 2 Address (see instructions)— Street (or route and box number) Apt. or Lot # City/Town State Zip Code 3 Address Where You Get Your Mail If Different From Above (see instructions) City/Town State Zip Code 4 Date of Birth Month Day Year 5 Telephone Number (optional) 6 ID Number (see item 6 in the instructions for your State) 7 Choice of Party (see item 7 in the instructions for your State) 8 Race or Ethnic Group (see item 8 in the instructions for your State) 9 I swear/affirm that: Please sign full name (or put mark) I am a United States citizen I meet the eligibility requirements of my state and subscribe to any oath required. (See item 9 in the instructions for your state before you sign.) The information I have provided is true to the best of my knowledge under penalty of perjury. If I have provided false information, I may be fined, imprisoned, or (if not a U.S. Date: citizen) deported from or refused entry to the United States. Month Day Year 10 If the applicant is unable to sign, who helped the applicant fill out this application? Give name, address and phone number (phone number optional). Fold here Please fill out the sections below if they apply to you. If this application is for a change of name, what was your name before you changed it? A Mr. Mrs. Miss Ms. Last Name First Name Middle Name(s) (Circle one) Jr Sr II III IV If you were registered before but this is the first time you are registering from the address in Box 2, what was your address where you were registered before? B Street (or route and box number) Apt. or Lot # City/Town State Zip Code If you live in a rural area but do not have a street number, or if you have no address, please show on the map where you live. C Route #2 Write in the names of the crossroads (or streets) nearest to where you live. NORTH Draw an X to show where you live. Use a dot to show any schools, churches, stores, or other landmarks near where you live, and write the name of the landmark. Example Grocery Store Woodchuck Road Public School X 1. Address the back of this application (see address under your state). 3. Fold form at middle and seal at top. To Mail: 2. Remove plastic strip below. 4. Put on a first-class stamp and mail. Which of the following is NOT a purpose of this form? a. notifying the government that you have changed your name b. registering with a political party c. applying for U.S. citizenship d. registering to vote in an upcoming local election