To conclude this training, you must complete this affidavit form.

This affidavit form provides the legally required Sworn Affidavit attesting that you will abide by all Virginia laws and rules regarding the registration of voters. Please be advised that criminal penalties may result from intentionally falsifying or misrepresenting material information on this form in violation of § 24.2-1016.  *Required if requesting over 25 voter registration applications; 200 maximum.

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* 1. I am a staff member of a local voter registration office and am entering this information for an individual or group which completed the training in my office.

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* 2. Please enter the requestor's full name:

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* 3. I am requesting voter registration applications from the Department of Elections or a local voter registration office for a voter registration drive (Check as applicable; limit 200 applications):

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* 4. I am requesting these forms as (Check as applicable):

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* 5. I will abide by all Virginia laws and rules regarding the registration of voters, including (Please check all, to affirm each statement below):

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* 6. If I am acting on behalf of an organization, I will use my best efforts to ensure that this organization will abide by all Virginia laws and rules regarding the registration of voters, which will include additional training and supervision of individuals working on behalf of my organization.

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* 7. I have completed the Virginia Department of Elections certified training approved by the Virginia State Board of Elections. I understand this annual certification is valid until June 30th each year, at which time I must complete the training again in order to renew my certification.

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* 8. I understand that criminal penalties may result from noncompliance, intentionally falsifying or misrepresenting material information.

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* 9. Please enter the following information:

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* 10. Please click button below to complete the affirmation:

  I so swear or affirm.
I swear or affirm under penalty of perjury that all statements and information I have provided on this form are true and correct.

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* 11. Date you completed this affirmation

Date 

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