Instructions:
Step 1: FILL-IN THE FORM BELOW AND CLICK THE SUBMIT PETITION
Step 2: VERIFY - Clicking the "Submit Petition" button will take you to the next page to verify the information is correct.
Step 3: PRINT the Petition -
Step 4: SIGN - DATE - MAIL - 2240 Woolbright Road, Suite 207, Boynton Beach, FL 33426 		 
     
 

FILL-IN THE PETITION FORM

  
 
1. NAME Enter Your Name/Address as it appears on Voter ID Card   Precinct
First Name
Middle
Last Name - Sr. Jr. II, III, etc.
 
Precinct
2. ADDRESS: Enter your address as it appears on Voter ID card
If you have changed your address you can enter your new address and
mark the change of address checkbox below "YES"
Street Address
Building
  
Apt/Unit/Floor
   
City
Zip
 
Phone: If there is a question about information on your petition (Optional)
Area   Exchange   Number   Extension
- - x
Email Address:
We appreciate being able to let you know if there is a question about information on your petition or
we would like to provide an email confirmation that your petition was counted.
Your privacy is secure, we NEVER share or sell your personal data.
3. COUNTY
Enter you
4a. VOTER REGISTRATION NUMBER  
If you have your voter registration number, enter the number. Do NOT confuse precinct number with registration number. If you do not have this number, you MUST enter your birth date below.
4b. BIRTHDATE
Please enter your date of birth which is used for identification purposes only
 
IS THIS A CHANGE OF ADDRESS FOR VOTER REGISTRATION?
YES
NO