Date of Birth:

Voter registration number (if available -- not required):

Phone number:

E-mail address:

Old Brevard County residence address:



Check if you want to keep this residence address
and make a mailing address change only

New Brevard County residence address:



Check if you do not have a permanent residence
address in Brevard County and are living outside of
the county but intend to remain a permanent resident
of the county. (If this applies to you, do not enter
an address in the space above)

Old mailing address (if different from residence address):



Check if you want to keep this mailing address
and make a residence address change only
Check if you now want your Brevard County
residence address to be your mailing address too

New mailing address (if different from residence address):

Please check any of the items below which apply to you:
I am now an active duty member of the military or a military dependent
I am no longer an active duty member of the military or a military dependent

Additional comments: