Full name: Email: Phone: Address: City: Zip: Representing (Name of Organization Distributing Cards): Address (Organization Distributing Cards): City: Zip: Quantity of English Forms: Quantity of English/Chinese Forms: Quantity of English/Korean Forms: Quantity of English/Spanish Forms: Quantity of English/Vietnamese Forms: Will you pick this up from our office, or would you like it mailed? (Orders of 200 or more require to be picked up at our office): I will pick it up at the Registrar's officePlease mail it to me Statement of Distribution Plans: Are you an NVRA agency as defined in the National Voter Registration Act?: YesNo Click here for more important information and printable documents for the National Voter Registration Act (NVRA). ANY MAILING OF VOTER REGISTRATION CARDS MUST BE IN COMPLIANCE WITH ELECTIONS CODE § 2158(b)(3). The code is on the next page. If you are collecting completed affidavits of registration, you must return completed affidavits of registration in your possession within three days, excluding Saturdays, Sundays and state holidays to the Registrar of Voters office. (Elections Code § 18103) I DECLARE UNDER PENALTY OF PERJURY THAT I WILL TAKE REASONABLE STEPS TO ENSURE THAT: (1) The person or persons distributing registration cards will give a registration card to any elector requesting one; and (Elections Code §§ 2158(b)(2), 18107) (2) The persons distributing registration cards will be fully advised that state law imposes PENALTIES OF IMPRISONMENT for anyone who knowingly and willfully completes affidavits of registration for NON-CITIZENS, NON-EXISTENT OR FICTITIOUS PERSONS, OR ANY INELIGIBLE ELECTOR ; and (Elections Code §§ 18100, 18101, and 18102) (3) The voter registration cards will not be defaced or changed in any way; and ( Elections Code §§ 2162(b), §18106) (4) The voter registration cards will not be partially or fully filled in by anyone other than the registrant or the person assisting the registrant in completing the form; (Elections Code § 2162[c]) (5) Persons entrusted with distribution or subsequent collection of completed registration forms will be fully advised of the legal requirements outlined on the reverse side of this statement. (Elections Code § 2159.5[a]) Any person who knowingly misrepresents himself or herself as having helped register another to vote on a registration form is guilty of a misdemeanor. (Elections Code §§ 18108.1, 2159[b]) I HAVE READ AND UNDERSTAND THE ABOVE ELECTIONS CODE SECTIONS. I HAVE RECEIVED, READ AND UNDERSTAND THE INSTRUCTIONS FOR COMPLETING REGISTRATION FORMS.