3rd Party Voter Registration Drive Sworn Affidavit and Application Request

Completing this form provides the legally required sworn affidavit attesting that you will abide by all Virginia laws and rules regarding the registration of voters. Please be advised that intentionally falsifying or misrepresenting material information on this form is in violation of § 24.2-1016, shall constitute the crime of election fraud, and be punishable as a Class 5 felony.

This form is required if requesting 25 or more voter registration applications.

Tell us about yourself

I am *

an individual (not affiliated with an organization)

an individual affiliated with an organization

a staff member at a local Voter Registration Office

a staff member at the Virginia Department of Elections

Locality *

Staff name *

This affidavit is for

First name *

Last name *

Organization (if any)

Address

Street Address (no PO boxes) *

Apt or Suite (if any)

City *

State *

Zip *

Phone 🛈

Email Address *

Request Voter Registration Applications

I am requesting voter registration applications from the Department of Elections or a local Voter Registration Office for a voter registration drive (limit 200 applications): *

Should you need immediate access to voter forms, you are also welcome to visit the Department of Election's website to download/print forms:

https://www.elections.virginia.gov/registration/voter-forms/

Sworn Affidavit

I have completed the Virginia Department of Elections certified training approved by the Virginia State Board of Elections. I understand this annual certification is valid until June 30th each year, at which time I must complete the training again in order to renew my certification. *

Yes

I will abide by all Virginia laws and rules regarding the registration of voters, including (Please check each to affirm): *

I will provide a completed receipt to all applicants for whom I take applications.

I will return all completed applications no later than ten (10) days after the applicant signs, or the close of registration for the next election, if sooner.

I will not mark, add, change, or delete any information on the Voter Registration Application, nor will I destroy or dispose of the application in any way.

I will not copy, duplicate, or distribute any social security number on any application.

If I am acting on behalf of an organization, I will use my best efforts to ensure that this organization will abide by all Virginia laws and rules regarding the registration of voters, which will include additional training and supervision of individuals working on behalf of my organization. *

Yes

Not applicable (I am not affiliated with an organization)

I understand that criminal penalties may result from noncompliance, intentionally falsifying, or misrepresenting material information. *

Yes

I swear or affirm under penalty of perjury that the foregoing is true and correct. *

I so swear or affirm.

Date of Affirmation * 🛈 +