Request Form

Reclaim Your Voice:

Register to become a JIIVE member today:
Please fill out this form if you are a Justice Impacted Individual on parole or probation and wish to harness your voting rights for change. All information provided will be kept confidential and used solely for the purpose of assisting you with your voter registration. 
1.Full Name:(Required.)
2.Date of Birth:
3.Current Residence Address:(Required.)
4.In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)
5.Background Information: State of Conviction:
6.Start date of Parole or Probation
7.Email Address(Required.)