Connecticut Statutes § 9-23h Application form

(1) Name,

(2) bona fide residence, including street number, street address, apartment number if applicable, town and zip code,

(3) telephone number,

(4) date of birth,

(5) whether the applicant is registered as an elector in any other town in the state of Connecticut or in any other state, and if so, the applicant's last previous voting residence,

(6) whether the applicant is a United States citizen,

(7) whether the applicant will be eighteen years of age on or before election day,

(8) party affiliation, if any,

(9) the applicant's signature and date of signature, and

(10) the applicant's Connecticut motor vehicle operator's license number or, if none, the last four digits of the applicant's Social Security number. The spaces for the applicant's telephone number and party affiliation shall indicate that such information does not have to be provided. On any such application printed on or after January 1, 2006, the space for the applicant's party affiliation shall also include a list of the names of the major parties, as defined in section 9-372 , as options for the applicant. The spaces regarding United States citizenship and whether the applicant will be eighteen years of age on or before election day shall indicate that if the applicant answers "No" to either question, the applicant may not complete the voter registration form. No Social Security number on any such form filed prior to January 1, 2000, may be disclosed to the public or to any governmental agency. The application shall contain a notice that if the applicant does not receive a notice of acceptance or rejection of the application from the office of the registrars of voters for the municipality in which the applicant resides, the applicant should contact said office. The application shall also contain any other information, questions or instructions prescribed by the Secretary of the State.