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MISSOURI VOTER REGISTRATION APPLICATION
Use this application to:
1. Register to vote in any election in Missouri. (New Registration)
2. Register
to vote when you move from one jurisdiction (St. Louis City, K ansas
City, or any county) to another jurisdiction (St.
Louis City, Kansas C
ity, o
r a
ny
county) within Missouri. (New Registration)
3. Change the address on a current voter
registration when you move
within a
jurisdiction. (Address Change)
4.
Change the name on a current voter
registration. (Name Change)
Other information:
1. You mus
t be 18 years of age by the day of a particular election to be eligible to
vote in that election.
2. If mailed, this form must be postmarked by the 4th Wednesday preceding an
election to be eligible to vote in that election. If delivered in person, it must be
received in the office of the election authority by the 4th Wednesday preceding an
election.
3. Submitting this application to an individual other than the election authority
does not insure timely voter registration.
4. After the election authority receives your voter registration application, you will be
sent confirmation within 7 business days. If you do not receive confirmation, contact
the election authority.
5. If you wish to serve as an election judge on election day please contact your local
election authority and mark the box at the bottom of this form.
6. Optional—If registering by mail for the first time, please submit a copy of one of the
following forms of identification: current or valid photo ID, current utility bill, bank
statement, government check, paycheck or other government document
that shows your name and address, birth certificate, Native American tribal document
or other proof of United States citizenship. (You will be required to present
identification when you vote.)
Completing this form (All information is required unless indicated as optional):
Boxes 1 and 2 -- Citizen and Age Requirements
Federal Law requires voter registration applicants to answer these two questions.
Box 3 -- Type of Application
Check appropriate box if this is a new registration or if you are changing a name or
address on your current voter registration.
Box 4 -- Name
Put in this box your full name (Last, First, Middle). DO NOT use nicknames or initials.
For name changes, Box 13 should contain your old name.
Box 5 --
Home Address
List
your home address. DO
NOT put
your mailing address if it differs from
your
home
address.
Box 6 --
Mailing Address
If
you get
your mail
at an address other than your home address in Box 5, put that
address here in this
box.
Box 7 --
Driver’s License Number
Required for
registration unless
you do not
have a Driver’s License. (§115.158,
RSMo.)
If you do not
have a Driver’s
License,
leave blank.
Box 8 --
Last
Four Digits
of Social Security Number
Required for
registration unless
you do not
have a Social Security Number.
(§115.155, RSMo, §115.158,
RSMo.)
If
you do not have a Social Security Number,
leave blank.
Box 9 --
Date of Birth
Place your date of
birth in this box (Month, Day,Year). DO NOT USE TODAY’S DATE!
Box 10
--
Place
of Birth (Optional)
List
your place of birth (city/county/state).
Box 11
--
Daytime Phone Number (Optional)
Please list
a number at
which the election authority may
contact
you for clarification of
information.
Box 12
--
Email Address (Optional)
Please list an email address at
which the election authority may contact
you for
clarification of information. This email address may only be used for election related
communication
from the election authority.
Box 13
-- Last Voter Registration
Information
If you are currently registered, please list the name and address of your last registration
including
county and state.
Box 1
4 -- Signature
Review
the information.
If you meet the requirements and all is correct, sign your
full name or make your mark and print today’s date.
Box 15 -- Rural Voters
If you live in a rural area without a street address, please supply information which may
help in placing you in the proper voting district.
YOUR APPLICATION WILL BE CONFIRMED BY MAIL WITHIN SEVEN (7) BUSINESS DAYS OF ITS RECEIPT BY THE
ELECTION AUTHORITY. PLEASE CONTACT THE ELECTION AUTHORITY IF YOU DO NOT RECEIVE NOTIFICATION.
MISSOURI VOTER REGISTRATION APPLICATION
USE PEN - PLEASE PRINT CLEARLY
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
If you checked no in response to either of the above questions, do not complete this form.
3
NEW REGISTRATION ADDRESS CHANGE NAME CHANGE
FOR OFFICE USE ONLY REGISTRATION NO.
4
LAST NAME FIRST NAME MIDDLE NAME
SUFFIX (JR, II, ETC.)
MALE FEMALE
5
ADDRESS WHERE YOU LIVE (HOUSE NO., STREET,APT. NO.OR RURALROUTE AND BOX- NO PO
BOXES)
CITY COUNTY ZIP CODE
6
ADDRESS WHERE YOU GET YOUR MAIL (REQUIRED IF DIFFERENT FROM #5 ABOVE)
CITY STATE ZIP CODE
7
DRIVER'S LICENSE NUMBER
IF YOU DO NOT HAVE A DRIVER'S LICENSE,
PLEASE LEAVE BLANK.
8
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER*
IF YOU DO NOT HAVE A SOCIAL SECURITY NUMBER, PLEASE LEAVE BLANK.
9
DATE OF BIRTH (MM/DD/YYYY)
10
PLACE OF BIRTH (OPTIONAL)
11
DAYTIME PHONE NO. (OPTIONAL)
12
EMAIL ADDRESS (OPTIONAL)
13
NAME AND ADDRESS ON LAST VOTER REGISTRATION
NAME
14
I hereby certify that I am a citizen of the United States and a resident of
the state of Missouri. I am at least seventeen and one half years of age. I
have not been adjudged incapacitated by any court of law. If I have been
convicted of a felony or a misdemeanor
connected with the right
of suffrage, I
have had the voting disabilities
resulting from such conviction removed
pursuant to law. I swear under penalty
of perjury that all
statements made
on this card are true to the best
of
my knowledge and belief. I understand
that if I register to vote knowing that I am not legally entitled to register, I am
committing a class one
election offense and may be punished by imprisonment
of not more than five years or by a fine of between two thousand five hundred
dollars and ten thousand dollars or by both such imprisonment and fine.
ADDRESS
CITY STATE
COUNTY
If currently registered in another state or county please complete this box.
15
RURAL VOTERS: COMPLETE THIS SECTION IF YOU LIVE OUTSIDE THE CITY LIMITS
OF ANY CITY.
I live
miles
(N S E or W) of
(landmark or junction)
Section,Township and range
Date
Signature
My neighbors are
Check here if you are interested in working as an Election Judge Warning: Conviction for making a false statement may result in imprisonment for up to five years and/or a fine up to $10,000.
MO 231-0169 (REVISED 02/17)
*Required for registration pursuant to §115.155 RSMo and §115.158 RSMo.
