08/2016
MISSISSIPPI MAIL-IN VOTER REGISTRATION APPLICATION
You can use this form to: register to vote in Mississippi or change your name and/or address.
If you are registering for the first time in Mississippi and DO NOT have a Mississippi driver’s license or social security
number, you must send with this application a copy of a current and valid photo ID or a copy of a current utility bill,
bank statement, government check, paycheck or other government document that shows your name and address in
this county.
An application for voter registration must be postmarked or hand delivered to the Circuit Clerk’s Office located in the
county of your voting residence no later than 30 days before an election.
You may not register to vote if you have been convicted in a Mississippi state court of any of the following crimes:
voter fraud, 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.
If you live in an area without house numbers or street names, please include a drawing of your location to enable us
to identify your appropriate voting precinct.
Photo ID Required to Vote: You will be required to present an acceptable form of photo identification when you vote
at your polling place on Election Day or by absentee ballot in your Circuit Clerk’s Office, unless exempted by
law. For more information, go to www.MSVoterID.ms.gov or call (844) 678-6837.
Check One:
New
Registration
Change of
Information
Are you a citizen of the United States of America?
Yes No
Will you be 18 years of age on or before Election Day?
Yes No
NOTE: If you checked ‘No’ in response to either of these questions, DO NOT complete this form.
Would you like to serve as an Election Day poll worker?
Yes No
Name
First Name
MI
Suffix
Physical Home
Address
(Where you live)
Number and Street/Road/Dorm/Apt #
County
State:
MS
Zip
Mailing Address
(If different from
above)
Street or Post Office Box
County
State:
Zip
Date of Birth
Month
Day
Year
MS Driver’s License
Number or Last 4
Digits of your Social
Security Number
_______________________
or
___ ___ ___ ___
Phone #
Home
( )
Work
( )
Previous
Registration
Name
Address
County
State:
Zip
VOTER DECLARATION- Read and Sign
I swear/affirm, under penalty of perjury, that:
I am a U.S. citizen.
I will be 18 years of age on or before the next general Election Day.
I am a resident of Mississippi, this county and this city for at least 30 days.
I have not been adjudicated as mentally incompetent.
I have never been convicted of voter fraud or any other disenfranchising crime OR, if convicted, I have had my voting
rights restored as required by law.
The address listed above is my legal place of residence.
WARNING: Giving false information to register to vote is a felony punishable by a fine of not more than $5,000 or
imprisonment for not more than 5 years, or both. Miss. Code Ann. § 23-15-17.
X __________________________________________________ Date: ______________________
Signature (or mark) of applicant
X ___________________________________________________ Date: _______________________
If applicant is unable to sign, the person who assisted the applicant
_______________________________________
Address
ADAMS COUNTY
115 S. Wall Street
Natchez, MS 39120
ALCORN COUNTY
P.O. Box 430
Corinth, MS 38835
AMITE COUNTY
P.O. Box 312
Liberty, MS 39645
ATTALA COUNTY
100 Courthouse, Ste. 1
Kosciusko, MS 39090
BENTON COUNTY
P.O. Box 262
Ashland, MS 38603
BOLIVAR COUNTY
P.O. Box 670
Cleveland, MS 38732
CALHOUN COUNTY
P.O. Box 25
Pittsboro, MS 38951
CARROLL COUNTY
P.O. Box 6
Vaiden, MS 39176
CHICKASAW COUNTY
1 Pinson Square, Rm. 2
Houston, MS 38851
CHOCTAW COUNTY
P.O. Box 34
Ackerman, MS 39735
CLAIBORNE COUNTY
P.O. Box 549
Port Gibson, MS 39150
CLARKE COUNTY
P.O. Box 216
Quitman, MS 39355
CLAY COUNTY
P.O. Box 364
West Point, MS 39773
COAHOMA COUNTY
P.O. Drawer 849
Clarksdale, MS 38614
COPIAH COUNTY
P.O. Box 467
Hazlehurst, MS 39083
COVINGTON COUNTY
P.O. Box 667
Collins, MS 39428
DESOTO COUNTY
2535 Hwy. 51 S., Rm. 201
Hernando, MS 38632
FORREST COUNTY
P.O. Box 992
Hattiesburg, MS 39403
FRANKLIN COUNTY
P.O. Box 267
Meadville, MS 39653
GEORGE COUNTY
355 Cox Street, Ste. C
Lucedale, MS 39452
GREENE COUNTY
P.O. Box 310
Leakesville, MS 39451
GRENADA COUNTY
P.O. Box 1517
Grenada, MS 38902
HANCOCK COUNTY
152 Main Street, Ste. B
Bay St. Louis, MS 39520
HARRISON COUNTY
P.O. Box 998
Gulfport, MS 39502
HINDS COUNTY
P.O. Box 327
Jackson, MS 39205
HOLMES COUNTY
P.O. Box 718
Lexington, MS 39095
HUMPHREYS COUNTY
P.O. Box 696
Belzoni, MS 39038
ISSAQUENA COUNTY
P.O. Box 27
Mayersville, MS 39113
ITAWAMBA COUNTY
201 W. Main Street
Fulton, MS 38843
JACKSON COUNTY
P.O. Box 998
Pascagoula, MS 39568
JASPER COUNTY
P.O. Box 447
Bay Springs, MS 39422
JEFFERSON COUNTY
P.O. Box 305
Fayette, MS 39069
JEFFERSON DAVIS COUNTY
P.O. Box 1090
Prentiss, MS 39474
JONES COUNTY
P.O. Box 1336
Laurel, MS 39441
KEMPER COUNTY
P.O. Box 130
De Kalb, MS 39328
LAFAYETTE COUNTY
1 Courthouse Sq., Ste. 101
Oxford, MS 38655
LAMAR COUNTY
P.O. Box 369
Purvis, MS 39475
LAUDERDALE COUNTY
P.O. Box 1005
Meridian, MS 39302
LAWRENCE COUNTY
P.O. Box 1249
Monticello, MS 39654
LEAKE COUNTY
P.O. Box 67
Carthage, MS 39051
LEE COUNTY
P.O. Box 762
Tupelo, MS 38802
LEFLORE COUNTY
P.O. Box 1953
Greenwood, MS 38935
LINCOLN COUNTY
301 S. First Street, Rm. 205
Brookhaven, MS 39601
LOWNDES COUNTY
P.O. Box 31
Columbus, MS 39703
MADISON COUNTY
P.O. Box 1626
Canton, MS 39046
MARION COUNTY
250 Broad Street, Ste. 1
Columbia, MS 39429
MARSHALL COUNTY
P.O. Box 459
Holly Springs, MS 38635
MONROE COUNTY
P.O. Box 843
Aberdeen, MS 39730
MONTGOMERY COUNTY
P.O. Box 765
Winona, MS 38967
NESHOBA COUNTY
401 E. Beacon Street, Ste. 110
Philadelphia, MS 39350
NEWTON COUNTY
P.O. Box 447
Decatur, MS 39327
NOXUBEE COUNTY
P.O. Box 431
Macon, MS 39341
OKTIBBEHA COUNTY
108 W. Main Street
Starkville, MS 39759
PANOLA COUNTY
P.O. Box 346
Batesville, MS 38606
PEARL RIVER COUNTY
P.O. Box 530
Poplarville, MS 39470
PERRY COUNTY
P.O. Box 198
New Augusta, MS 39462
PIKE COUNTY
P.O. Drawer 31
Magnolia, MS 39652
PONTOTOC COUNTY
P.O. Box 428
Pontotoc, MS 38863
PRENTISS COUNTY
P.O. Box 727
Booneville, MS 38829
QUITMAN COUNTY
220 Chestnut Street, Ste. 4
Marks, MS 38646
RANKIN COUNTY
P.O. Box 1599
Brandon, MS 39043
SCOTT COUNTY
P.O. Box 371
Forest, MS 39074
SHARKEY COUNTY
P.O. Box 218
Rolling Fork, MS 39159
SIMPSON COUNTY
P.O. Box 307
Mendenhall, MS 39114
SMITH COUNTY
P.O. Box 517
Raleigh, MS 39153
STONE COUNTY
323 E. Cavers Avenue
Wiggins, MS 39577
SUNFLOWER COUNTY
P.O. Box 880
Indianola, MS 38751
TALLAHATCHIE COUNTY
P.O. Box 86
Charleston, MS 38921
TATE COUNTY
201 Ward Street
Senatobia, MS 38668
TIPPAH COUNTY
102-A N. Main Street
Ripley, MS 38663
TISHOMINGO COUNTY
1008 Battleground Drive,
Rm. 2014
Iuka, MS 38852
TUNICA COUNTY
P.O. Box 184
Tunica, MS 38676
UNION COUNTY
P.O. Box 298
New Albany, MS 38652
WALTHALL COUNTY
200 Ball Avenue, Ste. C
Tylertown, MS 39667
WARREN COUNTY
P.O. Box 351
Vicksburg, MS 39181
WASHINGTON COUNTY
P.O. Box 1276
Greenville, MS 38702
WAYNE COUNTY
P.O. Box 428
Waynesboro, MS 39367
WEBSTER COUNTY
P.O. Box 308
Walthall, MS 39771
WILKINSON COUNTY
P.O. Box 327
Woodville, MS 39669
WINSTON COUNTY
P.O. Drawer 785
Louisville, MS 39339
YALOBUSHA COUNTY
P.O. Box 1431
Water Valley, MS 38965
YAZOO COUNTY
P.O. Box 108
Yazoo City, MS 39194
FROM:
TO: County Circuit Clerk
Postage
Required
Post Office will
not deliver
without proper
postage.
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