APPLICATION FOR REGISTRATION | ||||||
Are you a citizen of the United States? | ||||||
[] YES | [] NO | |||||
Will you be 18 years of age on or before election day? | ||||||
[] YES | [] NO | |||||
IF YOU CHECKED "NO" IN RESPONSE TO EITHER OF THESE QUESTIONS, DO NOT COMPLETE THIS FORM. | ||||||
IF YOU ARE SUBMITTING THIS FORM BY MAIL AND ARE REGISTERING FOR THE FIRST TIME, PLEASE SUBMIT A COPY OF A CURRENT, VALID PHOTO IDENTIFICATION. IF YOU DO NOT SUBMIT SUCH INFORMATION, YOU WILL BE REQUIRED TO PRESENT ADDITIONAL IDENTIFICATION UPON VOTING FOR THE FIRST TIME SUCH AS A BIRTH CERTIFICATE, A NATIVE AMERICAN TRIBAL DOCUMENT, OTHER PROOF OF UNITED STATES CITIZENSHIP, A VALID MISSOURI DRIVER'S LICENSE OR OTHER FORM OF PERSONAL IDENTIFICATION. | ||||||
__________________ | ||||||
Township (or Ward) | ||||||
__________________ | __________________ | |||||
Name | Precinct | |||||
__________________ | __________________ | |||||
Home Address | Required Personal Identification Information | |||||
__________________ | ||||||
City ZIP | ||||||
__________________ | __________________ | |||||
Date of Birth | Place of Birth | |||||
(Optional) | ||||||
__________________ | __________________ | |||||
Telephone Number | Mother's Maiden | |||||
(Optional) | Name (Optional) | |||||
__________________ | __________________ | |||||
Occupation (Optional) | Last Place Previously | |||||
Registered | ||||||
__________________ | __________________ | |||||
Last four digits of Social Security Number (Required for registration unless no Social Security Number exists for Applicant) | Under What Name | |||||
Remarks: | __________________ | |||||
When | ||||||
Political Party Affiliation | ||||||
(OPTIONAL: You shall be unaffiliated unless you designate an affiliation.) | ||||||
I am a citizen of the United States and a resident of the state of Missouri. I have not been adjudged incapacitated by any court of law. If I have been convicted of a felony or of a misdemeanor connected with the right of suffrage, I have had the voting disabilities resulting from such conviction removed pursuant to law. I do solemnly swear 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. | ||||||
__________________ | __________________ | |||||
Signature of Voter | Date | |||||
__________________ | ||||||
Signature of Election Official |
§ 115.155, RSMo