The form below is intended only for State and Public Agency representatives. If you are an individual voter receiving services from a State or Public Agency, print an agency PDF or use the Voter Registration Request Form to have one mailed to you. For individual voters and those planning a voter registration drive, please use the Voter Registration Request Form. State Agency DSHS – Community Services Division (CSD) DSHS – Aging & Long-Term Support Admin. (ALTSA) DSHS – Developmental Disabilities Admin. (DDA) DSHS – Division of Vocational Rehabilitation (DVR) Health Benefits Exchange (HBE) Dept. of Health (DOH) Health Care Authority (HCA) Dept. of Services for the Blind (DSB) Other Agency Specify agency Contact Name Mailing Address Mailing Address City State State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingOther… Enter other… Zip Phone Email Number of Voter Registration Forms  If you are an individual voter receiving services from a State or Public Agency, print an agency PDF (available in 23 languages) or use the Voter Registration Request Form to have one mailed to you.Agency-based Voter Registration Forms in additional languages are available to be printed on demand. Orders with no quantity cannot be fulfilled. English Chinese Spanish Vietnamese Submit
