11/2009
MISSISSIPPI MAIL-IN AND NVRA AGENCY 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 and mail 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.
If you decline to register to vote, your decision not to register will remain confidential and will be used only for voter registration
purposes.
If you do register to vote, the office at which you submit this application will remain confidential and will be used only for voter
registration purposes.
If this form is completed at an NVRA voter registration agency, record the name of the agency: ________________________________
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
3) Would you like to serve as an Election Day Poll Worker? Yes No
CIRCLE
Mr. Mrs.
Miss Ms.
Last Name: First Name: Middle/Maiden Name: Suffix: (JR, III)
Physical Home Address (Number & Street/Road/Dorm/Apt. #): * City: County: State: MS
Zip:
Mailing Address (if different from above, include zip code): Date of Birth: (mm/dd/yy)
Mississippi Driver’s License Number (If you do not have a driver’s license, then list the last 4 digits of your Social Security Number): **
*
If you reside at a non-traditional address attach a drawing or locational map of your address.
**
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 may 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, III)
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, under penalty of perjury, 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 any of the following
crimes against the State of Mississippi: murder, rape, bribery, theft, arson, obtaining money or goods under false pretense, perjury, forgery,
embezzlement, bigamy, armed robbery, extortion, felony bad check, felony shoplifting, larceny, receiving stolen property, robbery, timber larceny,
unlawful taking of a motor vehicle, statutory rape, carjacking, or larceny under lease or rental agreement, 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 person who assisted the applicant
must sign above
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. Miss. Code Ann § 23-15-
17.
FOR OFFICIAL USE ONLY
Was any person or group involved in the process of
completing this form other than the voter? If yes, the person or
group must provide the information below:
Name:________________________________________________
Address:______________________________________________
NOTE: If you checked “No” in response to questions
1 or 2, do not complete this form.
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