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
FOR OFFICE USE ONLY REGISTRATION NO.
LAST NAME FIRST NAME MIDDLE NAME
SUFFIX (JR, II, ETC.)
ADDRESS WHERE YOU LIVE (HOUSE NO., STREET, APT. NO. OR RURAL ROUTE AND BOX - NO PO
BOXES)
CITY COUNTY ZIP CODE
ADDRESS WHERE YOU GET YOUR MAIL (REQUIRED IF DIFFERENT FROM #5 ABOVE)
CITY STATE ZIP CODE
DRIVER'S LICENSE NUMBER LAST 4 DIGITS OF SOCIAL SECURITY NUMBER*
IF YOU DO NOT HAVE A DRIVER'S LICENSE, IF YOU DO NOT HAVE A SOCIAL SECURITY NUMBER, PLEASE LEAVE BLANK.
PLEASE LEAVE BLANK.
DATE OF BIRTH (MM/DD/YYYY) PLACE OF BIRTH (OPTIONAL) DAYTIME PHONE NO. (OPTIONAL)
3
9
7
6
5
4
*Required for registration pursuant to §115.155 RSMo and §115.158 RSMo.
NAME AND ADDRESS ON LAST VOTER REGISTRATION
NAME
ADDRESS
CITY STATE
COUNTY
If currently registered in another state or county please complete this box.
MISSOURI VOTER REGISTRATION APPLICATION
USE PEN - PLEASE PRINT CLEARLY
10
8
13
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.
Date
Signature
RURAL VOTERS: COMPLETE THIS SECTION IF YOU LIVE OUTSIDE THE CITY LIMITS OF
ANY CITY.
I live
miles
(landmark or junction).
Section,Township and range .
My neighbors are .
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 04-07)
MALE FEMALE
1
If you checked no in response to either of the above questions, do not complete this form.
2
Check here if you are interested in working as an Election Judge
NEW REGISTRATION ADDRESS CHANGE NAME CHANGE
11
12
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 this application to:
1. Register to vote in any election in Missouri.
2. Register to vote when you move from one jurisdiction (St. Louis City, Kansas
City, or any county) to another jurisdiction (St. Louis City, Kansas City, or any
county) within Missouri.
3. Change the address on a current voter registration when you move within a
jurisdiction.
4. Change the name on a current voter registration.
Other information:
1. You must 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. (See reverse for election calendar.)
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 12 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 -- Last Voter Registration Information
If you are currently registered, please list the name and address of your last registration
including county and state.
Box 13 -- 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 14 -- 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.
(DETACH HERE - KEEP TOP PORTION FOR YOUR RECORDS) This card is not proof of registration.
(N S E or W) of
