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GF    ^D2?Text Box 6J,  }SITE COORDINATOR TRAINING G@ H  0޽h ? 33y___PPT10Y+D=' 1= @B +"   0 '`(    HP?Rectangle 2pP  P NOverview 0 d  HIP?Rectangle 3 `  P hLegal Authority Registering: Initial intake & Recertification Transmittal Form Supply Ordering Remindersii i @`  ^?Text Box 4 'Agency-Based Voter Registration Program ((G ٝ (  @RP6lt6ltd&?6lt@6ltRectangle 5" @ 2    VP6lt6ltd&?6lt@6ltRectangle 6" P  2  H  0޽h ? 33___PPT10i.`a+D=' 1= @B +"  0N0   p  (     ^,eP?Text Box 2h 'Agency-Based Voter Registration Program ((G ٝ (  TgP6lt6ltd&?6lt@6ltRectangle 3" KY 2    S @ABTC,DEFQ>R"UVWX7:7:d&@5%?,T,TEE, @`,T,TEE,T,7:@7:Freeform 4" <h  C @ABTC,DEFQ>R"UVWXd@5%?,TE, @`,TE,T,Freeform 5" <hL  HTyP?Text Box 34p   National Voter Registration Act of 1993 All Department of Motor Vehicles Offices All Disability Agencies All Public Assistance Agencies NYS Election Law 5-211 Governs Agency-Based Voter Registration Procedures Includes additional State Designated Agencies ( 2f 2 2g 2 2' g g    HzP?Text Box 35p@  mLegal Authority 2    fP6lt6ltd&?6lt@6ltRectangle 36" @@ . 2  H  0޽h ? 33y___PPT10Y+D=' 1= @B +"  0N0 $0(  $ $ ^ĨP?Text Box 2h 'Agency-Based Voter Registration Program ((G ٝ ( $ ЫP6lt6ltd&?6lt@6ltRectangle 3" KY 2   $ S @ABTC,DEFQ>R"UVWX7:7:d&@5%?,T,TEE, @`,T,TEE,T,7:@7:Freeform 4" <h $ C @ABTC,DEFQ>R"UVWXd@5%?,TE, @`,TE,T,Freeform 5" <h $ ^ĴP?Text Box 6 zAdministrative HierarchyG v $ c N@ABCDEF QRUVWX&?@Freeform 7+ + v $ c N@ABCDEF QRUVWX&?@Freeform 8F  v  $ c N@ABCsDEF QRUVWX&?s@ssFreeform 9 + + G x  $ c P@ABCDEF QRUVWX&?@Freeform 10F bb x  $ c P@ABCDEF QRUVWX&?@Freeform 11 + + F x  $ c P@ABm CDEF QRUVWX&?m @m m Freeform 12F bF   $ VP&?Rectangle 142' 2   $ VP&?Rectangle 16^  2   $ V  $ `D?Text Box 24  fSiteG>  $ `?Text Box 25~, O xNYS Board of ElectionsG  $ `?Text Box 26S l Albany, NY  G  $ `>?Text Box 27p ,e  l Albany, NY  G  $ `A?Text Box 28 ; fSiteG>  $ ` C?Text Box 29 k Coordinator G$  $ `L?Text Box 30L4 k Coordinator G$  $ `D[?Text Box 31 k Coordinator G$   $ `pd?Text Box 32, P!  zAgency Program CoordinatorG H $ 0޽h ? 33y___PPT10Y+D=' 1= @B +"  0 (E(  (  ( H?Rectangle 2    m'Agency-Based Voter Registration Program(($ٝ (  ( H?Rectangle 3P  Agency must offer voter registration during initial intake and recertification. Voter registration has no impact on applicant s benefits. Client s information will be used for voter registration purposes only and will otherwise remain confidential (including office of origin.) Voter Registration Forms are available in English, Spanish, Chinese, and Korean.hPZZ:ZZZZQZj j @` ( C @ABTC,DEFQ>R"UVWXd@5%?,TE, @`,TE,T,Freeform 4" <hH ( 0޽h ? 33___PPT10i. @+D=' 1= @B +"d 0N0 c[,(  ,. , ^?Text Box 2 P  @Response #1 - Client says  YES !!G0 ! , TH?Rectangle 4I  2   , ^?Text Box 5dp . 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(#!'*- 147:=@CFILNQTVY\^adfixkqnjpcs\uUxN{H}A;5.(" 68@58YS M GA;5. (#!'*- 147:=@CFILNQTVY\^adfixkqnjpcs\uUxN{H}A;5.(" 58YFreeform 15@] 4  b@ABCDEFQ.RUVWX?  @  Freeform 16%]s@x 4  P@ABC DEFQ&RUVWX? @  Freeform 17ss%T 4  ,@AB4CDEF QRUVWX&?@4Freeform 18dlmT 4  ,@ABCDEF QRUVWX&?@Freeform 19d T 4  ,@ABCDEF QRUVWX&?@Freeform 20d T 4  ,@ABCDEF QRUVWX&?@Freeform 21d88 4 `$?Text Box 22  a2G  T 4  ,@ABCDEF QRUVWX&?@Freeform 23d 4 `D?Text Box 24GC8  Are you a U.S. citizen? 0FGG   4 `?Text Box 25 D> .If you answered NO, do not complete this form.//G / 4 `?Text Box 26D; b 1G   4 `,?Text Box 27 9  I will be 18 years old on or before election day: Yes & No & If you answered NO, do not complete this form, unless you will be 18 by the end of the year. G G1G GGGG GG G GG gG G z 4 `?Text Box 28B  X Yes & No &N-G E G E -H 4 0޽h ? 33y___PPT10Y+D=' 1= @B +" ? 0N0 >>8)>(  8L 8 ^tB?Text Box 2GK & Yes, I need an application for an absentee ballot & Yes, I would like to be an Election Day worker vG3GG.GG G R 8  *@AB C4DEF QRUVWX? @  4Freeform 3ENR 8  *@AB CDEF QRUVWX? @  Freeform 4v 8 ^D?Text Box 5 - a2G  R 8  *@ABCDEF QRUVWX?@Freeform 6CCR 8  *@ABCDEF QRUVWX?@Freeform 7V V R 8  *@AB4CDEF QRUVWX?@4Freeform 8HIR  8  *@ABCDEF QRUVWX?@Freeform 9 2  8 L\?Oval 104v v 2  x  8  P@ABCDEFQ&RUVWX? @ Freeform 11   8  @ABC5DE,FQ^R2UVWX?    ! ) /354 @    ! ) /354 5Freeform 12 (  8  @ABQCDEpF@QRvUVWX?  y#q&j)c,\.T1M4F6?98;1>*@#CFIK NQ @  y#q&j)c,\.T1M4F6?98;1>*@#CFIK NQQFreeform 13G  x 8  P@AB CDEFQ&RUVWX?  @   Freeform 148  Gx 8  P@ABCDEFQ&RUVWX?@Freeform 153  8R 8 `Th?Text Box 16H\}e b & Yes, I would like to be an Election Day worker22G  2 8  @AB&C.DE FQFR&UVWX?   #&. @   #&.&.Freeform 17T 8  @AB$CeDEXF4QR^UVWX? %-4;BIOUZ_bde!e$c@ %-4;BIOUZ_bde!e$c$eFreeform 18  8  @ABCYDEFrQRUVWX?55YS M GA;5. 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G 1GGE GG GE G EG ^GE v <  N@ABCDEFQ&RUVWX? @ Freeform 2Xh <  r@ABC"DEFQ6RUVWX?!"@!""Freeform 3h` <  8@AB CvDEDF*QRJUVWX?voha Z RJB:2*#  @voha Z RJB:2*#   vFreeform 4v <  N@ABC DEFQ&RUVWX? @  Freeform 5 v  <  N@ABCDEFQ&RUVWX?@Freeform 6 d  < 3 <@ABTCTDEF QRUVWX?TT@TTTTFreeform 7=R  < ^l?Text Box 8  !You must be a U.S citizen to vote""G  "v  <  N@ABCDEFQ&RUVWX?  @  Freeform 9 1  <  @ABC5DE,FQ^R2UVWX?    ! ( . 353 @    ! 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Number (optional) M F G R L  *@ABCDEF QRUVWX?@Freeform 3wGwR L  *@ABCDEF QRUVWX?@Freeform 4GR L  *@ABCDEF QRUVWX?@Freeform 5R L  *@ABCDEF QRUVWX?@Freeform 6GG L ^?Text Box 7  h12/12/54 G( R L  *@ABCDEF QRUVWX?@Freeform 8R  L  *@ABCDEF QRUVWX?@Freeform 9y2  L L?Oval 10 ,  2    L `T?Text Box 117 l 222-333-5555 G$ T  L  ,@ABCDEF QRUVWX?@Freeform 12 T  L  ,@ABCDEF QRUVWX?@Freeform 13l l T L  ,@ABCDEF QRUVWX?@Freeform 14 L `?Text Box 15l a6G   L `?Text Box 16L  a7G   L `?Text Box 174 a8G  H L 0޽h ? 33y___PPT10Y+D=' 1= @B +" ~  0N0 } u 0 P (  P P ^?Text Box 2{  ID Number - Check the applicable box and provide your number & New York DMV number __ __ __ __ __ __ __ __ __ If you do not have a New York DMV number, please provide & Last four (4) digits of your Social Security number ___ ___ ___ ___ & I do not have a New York DMV number or a Social Security number =GL\<GG iGG :GGG KG DR P@  *@ABtC|DEF QRUVWX?|@|t|Freeform 4p R P  *@ABu#C|DEF QRUVWX?|@|u#|Freeform 5% R P@  *@ABt#C|DEF QRUVWX?|@|t#|Freeform 6D R P  *@ABLCDEF QRUVWX?L@LLFreeform 7 \  P f0?Rectangle 8P _9G   R P  *@ABLCDEF QRUVWX?L@LLFreeform 9DH  P 0޽h ? 33y___PPT10Y+D=' 1= @B +"  0N0 @Tz(  TR T  *@ABCDEF QRUVWX?@Freeform 2wRwR T  *@ABCDEF QRUVWX?@Freeform 3D$R T  *@ABCDEF QRUVWX?@Freeform 4hxR T  *@ABCDEF QRUVWX?@Freeform 5zLLx T ^;?Text Box 6 d2003G( R T  *@ABCZDEF QRUVWX?Z@ZZFreeform 7 T ^DHLNNL@  ")18>DHLNNLNFreeform 11    X  @ABuCDEFXQFRUVWX?(( "%),/257:=@B}EvHoJgM`OYRRUKWDZ=\6_0b)d#gjlo ru),@(( "%),/257:=@B}EvHoJgM`OYRRUKWDZ=\6_0b)d#gjlo ru((uFreeform 12 ; x  X  P@ABCDEFQ&RUVWX? @ Freeform 13 ;L x X  P@ABCDEFQ&RUVWX?@Freeform 14 LL T X  ,@ABu#C DEF QRUVWX&? @ u# Freeform 15 H X 0޽h ? 33y___PPT10Y+D=' 1= @B +" I  0N0 H@`\(  \R \  *@ABCDEF QRUVWX?@Freeform 2tRtR \  *@ABCDEF QRUVWX?@Freeform 3] R \  *@ABC| DEF QRUVWX?| @| | Freeform 4NN8 \ ^?Text Box 5p Please note: In order to vote in a primary election, you must be enrolled in one of these parties. The Independence Party allows un-enrolled voters to vote in their primaries.  G0G0G0/G0G G0 G0$G0G( R \  *@ABC DEF QRUVWX? @  Freeform 6s  H \ 0޽h ? 33y___PPT10Y+D=' 1= @B +" X 0N0 WOp `(  `R `  *@ABCDEF QRUVWX?@Freeform 2O5OR `  *@ABCDEF QRUVWX?@Freeform 3AR `  *@ABChDEF QRUVWX?h@hhFreeform 4Z00 ` ^t?Text Box 5w,I  @AFFIDAVIT: I swear or affirm that % I am a citizen of the United States % I will have lived in the county, city, or village for at least 30 days before the election. % I meet all requirements to register in vote in New York State % This is my signature or mark on the line below. % The above information is true. I understand that if it is not true I can be convicted and fined up to $5,000 and/or jailed for up to four years.`!G G(GG%G G(GG `GGG?GG GG0G GGG  R `  *@ABCuDEF QRUVWX?u@uuFreeform 6N ` ^?Text Box 7  + Signature or mark X Date,,G$ , ` 3 @ABECqDEF`QRUVWX?qmjfb]~XvSnNeI]DT>K9C4;/3*+%$           ( 4 ? 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If you are not registered to vote where you live now, would you like to apply to register here today? hhG* h p ^@?Text Box 8@n u4 possible responses:G0 H p 0޽h ? 33y___PPT10Y+D=' 1= @B +"  0N0 ]^tp(  t t `9FA?Rectangle 2  2   t N)?Rectangle 3w 2   t `$EFA?Rectangle 4 2   t NN?Rectangle 5 2   t `HWFA?Rectangle 6& 2   t N`?Rectangle 7 2  V t ^h?Text Box 8PU .NO because I choose not to register to vote ORV/G$G$)GG /W  t ^m?Text Box 9x  iIf you do not check any box, you will be considered to have decided not to register to vote at this time.jjG$ j(  t `$~?Text Box 10   8(Signature) Date99G$ 9T  t  ,@AB#CDEF QRUVWX?#@##Freeform 11} }   t hX?Rectangle 12 ~  m/ / /G$     t h|?Rectangle 13["M q(Please Print Name)G$  T t  ,@AB$CDEF QRUVWX?$@$$Freeform 14HH t  @AB%C0DE FQFR&UVWXD?   %%0 @   %%0%0Freeform 15!% t  @AB$CiDE\F6QRbUVWXD? %,3:AHOU[_cfhi"i$g@ %,3:AHOU[_cfhi"i$g$iFreeform 16%!E t  @ABCgDEFvQRUVWXD?77ga[ UOIC<6!/%)("+.1 47:=@BEHKMPRUWZ\_adf~hwkpmjpcr\tUwOyH|A~;5.(" 88@78ga[ UOIC<6!/%)("+.1 47:=@BEHKMPRUWZ\_adf~hwkpmjpcr\tUwOyH|A~;5.(" 78gFreeform 17%E t  b@ABCDEFQ.RUVWXD?  @  Freeform 18 %x t  P@ABC DEFQ&RUVWXD? @  Freeform 19   t `ܠ?Text Box 20$ 0I am already registered at my current address OR11G 1 t  t@AB C'DEFQ6RUVWX&? 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[To be completed by agency site coordinator].8 G$-G 8  T?Rectangle 4 2    T?Rectangle 5js 2    T ?Rectangle 6-s 2    ft?Rectangle 7H"p {NVRA 6-digit Site Code NumberG   R   *@ABCDEF QRUVWX?@Freeform 8E  T"?Rectangle 9sz 2     h$?Rectangle 10  qDate of TransmittalG$  T   ,@ABCDEF QRUVWX?@Freeform 11G  h/?Rectangle 12cX f106459G-    h??Rectangle 13Dd  g8/01/10G&  H  0޽h ? 33y___PPT10Y+D=' 1= @B +"  0N0  T(  X  ^M?Text Box 2gQ XApplications [Number who registered to vote, changed address, name or party enrollment].Y G$LG Y0  ^xH?Text Box 3]#" BNumber of voter registration applications contained in transmittalCCG C  T_?Rectangle 4   2    Tli?Rectangle 5jJ 2  R   *@ABCUDEF QRUVWX?U@UUFreeform 62  J m^?Oval 7!E+ 2    ft?Rectangle 8z d 20GH  H  0޽h ? 33y___PPT10Y+D=' 1= @B +"   0N0    k (    ^Ā?Text Box 26 i *Agency-Based Registration Transmittal Form++G$ +<  ^Ԋ?Text Box 3 <Declinations [Number received since last transmittal.......].= G$0G =  TD?Rectangle 4 2    T?Rectangle 5js 2    Tܭ?Rectangle 6*s  2    f?Rectangle 7*i $Enter the number who checked the NO %%G  % R   *@ABCDEF QRUVWX?@Freeform 86+ !  ^?Text Box 9k 3Box on the agency-based form OR left the form blank44G  4  `l?Text Box 10,L0 b58G< H  0޽h ? 33y___PPT10Y+D=' 1= @B +" < 0N0 ;3 (  <  ^?Text Box 2 <Declinations [Number received since last transmittal.......].= G$0G =  T?Rectangle 3js 2    T?Rectangle 4*s 2    f?Rectangle 59 %(  "Enter the number who checked the ##G  # R   *@ABCDEF QRUVWX?@Freeform 66+    ^D ?Text Box 7P y  2ALREADY REGISTERED box on the agency- based form 33G  3  ^X ?Text Box 8   b75G<   ^ ?Text Box 9b *Agency-Based Registration Transmittal Form++G$ +  V ?Rectangle 10e  2    h  ?Rectangle 11*w $Enter the number who checked the NO %%G  % T   ,@ABCkDEF QRUVWX?k@kkFreeform 12 f #  `' ?Text Box 13t 3Box on the agency-based form OR left the form blank44G  4  `H2 ?Text Box 14M" b58G<   V< ?Rectangle 15CTH 2  H  0޽h ? 33y___PPT10Y+D=' 1= @B +"  0N0 0F(  <  ^I ?Text Box 24p <Declinations [Number received since last transmittal.......].= G$0G =  T@X ?Rectangle 3L>N 2    T0\ ?Rectangle 44>N 2    fhc ?Rectangle 57'  "Enter the number who checked the ##G  # R   *@ABCDEF QRUVWX?@Freeform 6g66m   ^,m ?Text Box 73 xX  2ALREADY REGISTERED box on the agency- based form 33G  3  ^o ?Text Box 8A  b75G<   ^ ?Text Box 9a *Agency-Based Registration Transmittal Form++G$ +  VL ?Rectangle 10Kv  2    h\ ?Rectangle 11hk*? $Enter the number who checked the NO %%G  % T   ,@ABC|DEF QRUVWX?|@||Freeform 12'CC #  `$ ?Text Box 13pxQ 3Box on the agency-based form OR left the form blank44G  4  ` ?Text Box 14*M8 b58G<   Vd ?Rectangle 15BRH 2    VԻ ?Rectangle 16 Kv 2  5  ` ?Text Box 17 lD EAND RECEIVED A MAIL REGISTRATION FORM box on the agency- based form FFG F   h ?Rectangle 18; y%  *Enter the number who checked the REQUESTED++G + T   ,@ABCDEF QRUVWX?@Freeform 19 OO  `h ?Text Box 20 7 b30GP H  0޽h ? 33y___PPT10Y+D=' 1= @B +"   0N0 @ j(  G  ^| ?Text Box 2)9 IOther Applications [Individuals who did NOT appear at your agency office],JG$7E J  ^ ?Text Box 3F( *Agency-Based Registration Transmittal Form++G$ +6  ^D"?Text Box 4D+q JEnter the number (if any) of voter registration forms SENT to individuals.KKE K  T"?Rectangle 5AH 2    T"?Rectangle 6'( 2    TH"?Rectangle 7; 2  R   *@ABCDEF QRUVWX?@Freeform 8T  ^"?Text Box 9S c250G  H  0޽h ? 33y___PPT10Y+D=' 1= @B +"   0N0   P  (    ^ "?Text Box 2m^s fBLANKSG:   f2"?Rectangle 3  _!Gc  R   *@ABuCDEF QRUVWX?u@uuFreeform 4L  ^E"?Text Box 52-I2 P' Applicant refuses to make any marks on the agency-based form.PG,OG$ P  ^J"?Text Box 6# #  P' Applicant is unable to respond to voter registration question.JG,IG$ J@  ^R"?Text Box 7 :  @P' Applicant is not a US citizen.!G, G$ !B  ^8]"?Text Box 8 `<  BP' Applicant is a convicted felon."G,!G$ "R  ^S"?Text Box 9d RP' Multiple checkmarks in declination area.*G,)G$ *H  0޽h ? 33y___PPT10Y+D=' 1= @B +" >+ 0N0 =*5*`*+)(  *  ^P{"?Text Box 2?| > Declinations [Number received since last transmittal.......]??E ?  f}"?Rectangle 3j 3  ~"Enter the number who checked the ##E # (  ^,"?Text Box 4e l  <ALREADY REGISTERED box on the agency- based form ==E =  ^"?Text Box 5 n  `75E   ^"?Text Box 6Zo 0Agency-Based Voter Registration Transmittal Form11E 1  T,"?Rectangle 7KiA  2    f"?Rectangle 8 $Enter the number who checked the NO %%E % R   *@ABCKDEF QRUVWX?K@KKFreeform 9 X 0  `|"?Text Box 10 L  BBox on the agency-based form OR left the form blankCCE C  Vd"?Rectangle 11=M 2    VP"?Rectangle 12 KiX  2  6  `0"?Text Box 13p H  6MAIL REGISTRATION FORM box on the agency- based form ,75EG 7-  h"?Rectangle 14 u&i  9Enter the number who checked the REQUESTED AND RECEIVED A::E :   `P"?Text Box 15A   `30E %  `"?Text Box 16L 7Section I. [To be completed by agency site coordinator]88E 8  h#?Rectangle 178  yNVRA 6-digit Site Code NumberE    h#?Rectangle 18k < oDate of TransmittalE    h #?Rectangle 19;I( f106459G    h "#?Rectangle 20 g8/01/10G    V +#?Rectangle 217Q 2    V3#?Rectangle 22D^ 2    V8#?Rectangle 23D^ 2  T   ,@AB CDEF QRUVWX? @  Freeform 24|  `\J#?Text Box 25`  XApplications [Number who registered to vote, changed address, name or party enrollment]PY EGG$,G Y  VR#?Rectangle 26D^ 2    VU#?Rectangle 27D^ 2    Vd#?Rectangle 28Qk 2  0  `g#?Text Box 29^4 BNumber of voter registration applications contained in transmittalCCE CT   ,@ABCDEF QRUVWX?@Freeform 31   Vj  2   " VL#?Rectangle 35q Pn|  2  I # `#?Text Box 36 DZ  IOther Applications [Individuals who did NOT appear at your agency office],JE7G J $ VԠ#?Rectangle 37q Pn|  2  8 % `#?Text Box 38l JEnter the number (if any) of voter registration forms SENT to individuals.KKE K & V#?Rectangle 39 Ca 2  T '  ,@ABCDEF QRUVWX?@Freeform 40  ( `D#?Text Box 41eZ  `58E  ) `#?Text Box 42  a250E  * `p#?Text Box 43 `20E H + 0޽h ? 33y___PPT10Y+D=' 1= @B +" 0 0N0 /'p(    Tt#?Rectangle 2s 2  R   *@ABCDEF QRUVWX?@Freeform 3  Tl#?Rectangle 4 s  2  R   *@ABCDEF QRUVWX?@Freeform 5  T#?Rectangle 6;s  2  R   *@ABCDEF QRUVWX?@Freeform 7:   T#?Rectangle 8- s=  2  R   *@ABCDEF QRUVWX?@Freeform 9; <   V$?Rectangle 10r 2    V $?Rectangle 11L r  2    V$?Rectangle 12Wr 2    V8$?Rectangle 13 rV 2  T   ,@ABCDEF QRUVWX?@Freeform 14[  T   ,@ABCUDEF QRUVWX?U@UUFreeform 15UT   ,@ABCDEF QRUVWX?@Freeform 16 s  `0$?Text Box 17u 3Number of new registrations contained in this batchz4 GGGG GG 4*  `p*$?Text Box 18LD :Section II. 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