HTML Preview Electoral Registration Form Printable page number 1.
Surname
If your surname has changed since you last registered,
please give your previous surname in the box below.
First Name
All Middle Names
Address
I apply to be registered at the following address where I am now living
House or
Flat number
Street name
Town or city
Postcode
Anyone can buy a copy of the edited register, including companies
that send junk mail. If you don’t want your details to appear on the
edited register tick here.
If you require an Electoral Identity Card tick here.
Previous address If your address has changed since you
last registered, please give your old address below
Other address (with postcode)
Only fill in this section if you have any other address in the United
Kingdom where you are, or have applied to be, registered.
Nationality (for example British, Irish, French )
Date of birth (DD/MM/YYYY)
National insurance number
(for example AB123456D)
Tick this box if you have never had a National
Insurance number
Phone number we will only use this number if we need to
check anything
I am a British, Irish, Commonwealth or European citizen. The information I have given on this form is correct.
You must sign this form in the box below, unless you are unable because of an incapacity or because you are unable to read.
No-one else can sign it for you.
*** Please keep all of your signature inside the white
box, otherwise we may return the form to you.
Date
If you cannot sign the form because of an incapacity or because you are unable to read, you must ask a witness to fill in the section
below for you.
The person whose details are given on this form has told me that the information is correct. That person is unable to sign the form
*because of an incapacity/because they are unable to read (*delete as appropriate)
Signature of witness Address of witness
EDITED REGISTER (see accompanying notes )
YOUR DETAILS
DECLARATION
OFFICE USE ONLY
DWP verified
Signature
check
Processed Approved
DB EROS
Ward
Code
WS
ELECTORAL ID CARD (see accompanying notes)
ELECTORAL REGISTRATION FORM
After completing this form, please
sign it with a BLACK PEN.