Voters Preference Registration Form

First Name

Middle Name

Last Name

If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Check One Box)

Already registered. I am registered to vote at my current residence address.

Yes. I would like to register to vote. (Please contact ACCESS@barstow.edu to get information on how to obtain a voters Registration form)

No. I do not want to register to vote.

Signature and Date

Sign above

Important Notices
1. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this
agency.
2. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help
is yours. You may fill out the voter registration form in private.
3. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in
deciding whether to register or in applying to register to vote, or your right to choose your own political party preference or
other political preference, you may file a complaint with the Secretary of State by calling toll-free (800) 345-VOTE (8683)
or you may write to: Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814. For more information on elections and
voting, please visit the Secretary of State’s website at www.sos.ca.gov.

Main Campus

Fort Irwin Campus