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Mississippi Voter Registration Application

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Mississippi Voter Registration Application
Mississippi Voter Registration Application
MISSISSIPPI VOTER REGISTRATION APPLICATION
IMPORTANT!
If you are not registered to vote where you now live, you can use this form to register to vote or report that your name or
address has changed.
If you have questions call your county Circuit Clerk or call the Secretary of State at 1-800-829-6786.
Complete all sections of this form, then mail or hand deliver it to your county Circuit Clerk AT LEAST 30 days before the
election in which you want to vote.
If you are qualified and the information on your form is complete, you will be mailed a voter card that tells you where to
vote.
Section I. APPLICATION TO REGISTER TO VOTE
Please select one of the following: New Registration Change of Information
1) Are you a citizen of the United States of America Yes No
2) Will you be 18 years of age on or before election day Yes No
CIRCLE
Mr. Mrs.
Miss Ms.
Last Name: First Name: Middle/Maiden Name: Suffix: (JR, II)
Physical Home Address (Number & Street/Road/Dorm/Apt. or Lot #):
City:
County:
State: MS
Zip:
Mailing Address (if different from above, include zip code):
Date of Birth:
Driver’s License Number (If you do not have a driver’s license, then list the last 4 digits of your Social Security Number): ***
***Identification Requirement: If you do not have a driver’s license or social security number, and this form is submitted by mail,
and you have never registered to vote in the county you are now registering in, you must send, with this application, either a) a
copy of current and valid photo identification, or b) a copy of a current utility bill, bank statement, government check, paycheck, or
other government document that shows the name and address of the voter. If you do not provide the information requested above,
you will be required to provide to election officials either (a) or (b) above the first time you vote after January 1, 2004 at a voting
place or by absentee ballot.
Section II. IF YOU WERE PREVIOUSLY REGISTERED UNDER A DIFFERENT NAME OR ADDRESS, LIST THAT NAME OR ADDRESS
CIRCLE
Mr. Mrs.
Miss Ms.
Last Name: First Name: Middle/Maiden Name: Suffix: (JR, II)
Previous Address (Number & Street/Road/Dorm/Apt. or Lot #):
Previous City: Previous County: Previous State: Previous Zip:
Section III. VOTER DECLARATION- Read and Sign
I swear/affirm that: I am a U.S. citizen. I will have lived in this state and county for at least 30 days before voting, and if a resident
of a municipality, I will have lived in the municipality for at least 30 days before voting. I have never been convicted of murder,
rape, bribery, theft, arson, obtaining money or goods under false pretense, perjury, forgery, embezzlement, or bigamy, or I have
had my rights restored as required by law. I have not been declared mentally incompetent by a court. Furthermore, I certify that I
am at least eighteen (18) years old (or I will be before the next general election), the information given by me is true and correct
and that I have truly answered all questions on this application for registration, and that I will faithfully support the Constitution of
the United States and of the State of Mississippi, and will bear true faith and allegiance to the same.
X ______________________________________________________ Date: ______________________
Signature (or mark) of applicant
X ______________________________________________________
Date: _______________________
If applicant is unable to sign, the signature of the person who
Helped fill out this application is required to sign.
_____________________________________________
Daytime phone number(s) where applicant can be reached
WARNING: False registration is a felony. The penalty for conviction of
false registration is imprisonment for not more than five (5) years or a
fine of not more than five thousand dollars ($5000), or both.
NOTE: If you checked “No” in response to
questions 1 or 2, do not complete this form.
For Office Use Only
Mississippi Voter Registration Application
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