Missouri Voter Registration Application
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2MISSOURI VOTER REGISTRATION APPLICATION
Use this application to:
Box 7 – Driver’s License Number
Required for registration unless you do not have a Driver’s License.
1.
Register to vote in any election in Missouri.
(§115.158, RSMo.) If you do not have a Driver’s License, leave blank.
2.
Register to vote when you move from one jurisdiction (St. Louis City,
Kansas City, or any county) to another jurisdiction (St. Louis City,
Box 8 – Last Four Digits of Social Security Number
Required for registration unless you do not have a Social Security
Kansas City, or any county) within Missouri.
Number. (§115.155, RSMO, §115.158, RSMo.) If you do not have a
3.
Change the address on a current voter registration when you move
Social Security Number, leave blank.
within a jurisdiction.
Box 9 – Date of Birth
4.
Change the name on a current voter registration.
Place your date of birth in this box (Month, Day, Year). DO NOT USE
TODAY’S DATE.
Completing this form (All information is required unless indicated
as optional):
Box 10 – Place of Birth (Optional)
Box 1 and 2 – Citizen and Age Requirements
List your place of birth (city/county/state).
Federal Law requires voter registration applicants to answer these two
questions. If box 1 or 2 is left blank the registration will be incomplete and
Box 11 – Daytime Phone Number (Optional)
returned to the applicant.
Please list a number at which the election authority may contact you for
clarification of information.
Box 3 – Type of Application
Check appropriate box if this is a new registration or if you are changing
Box 12 – Last Voter Registration Information
a name or address on your current voter registration.
If you are currently registered, please list the name and address of your
last registration and county.
Box 4 – Name
Box 13 – Signature
Put in this box your full name (Last, First, Middle). DO NOT use nicknames
Review the information. If you meet the requirements and all is correct,
or initials. For name changes, Box 12 should contain your old name.
sign your full name or make your mark and print today’s date.
Box 5 – Home Address
Box 14 -- Rural Voters
Put in this box your home address. DO NOT put your mailing address if it
If you live in a rural area without a street address, please supply informa-
differs from your home address.
mation which may help in placing you in the proper voting district.
Box 6 – Mailing Address
If you wish to serve as an election judge on election day please
If you get your mail at an address other than your home address in Box
contact your local election authority and mark the box at the bottom
5, put that address here.
of this form.
MISSOURI VOTER REGISTRATION APPLICATION
Code 02
USE PEN – PLEASE PRINT CLEARLY
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
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2
If you checked no in response to either of the above questions, do not complete this form
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NEW REGISTRATION
ADDRESS CHANGE
NAME CHANGE
FOR OFFICE USE ONLY
REGISTRATION NO.
4
LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX (CIRCLE)
MALE
FEMALE
JR.
SR. II
III
IV
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ADDRESS WHERE YOU LIVE (HOUSE NO., STREET, APT. NO. OR RURAL ROUTE AND BOX-
CITY
COUNTY
ZIP CODE
NO PO BOXES)
ADDRESS WHERE YOU GET YOUR MAIL (REQUIRED IF DIFFERENT FROM #5 ABOVE)
CITY
STATE
ZIP CODE
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7
DRIVER’S LICENSE NUMBER
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER*
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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)
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10
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/
/
NAME AND ADDRESS ON LAST VOTER REGISTRATION
I hereby certify that I am a citizen of the United States and a resident of the state of
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Missouri. I am at least seventeen and one half years of age. I have not been
NAME_____________________________________________________
adjudged incapacitated by any court of law. If I have been convicted of a felony or a
ADDRESS _________________________________________________
misdemeanor connected with the right of suffrage, I have had the voting disabilities
CITY ____________________________STATE ___________________
resulting from such conviction removed pursuant to law. I swear under penalty of
COUNTY __________________________________________________
perjury that all statements made on this card are true to the best of my knowledge
If currently registered in another state or county please complete this box.
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
RURAL VOTERS: COMPLETE THIS SECTION IF YOU LIVE OUTSIDE
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imprisonment of not more than five years or by a fine of between two thousand five
THE CITY LIMITS OF ANY CITY.
hundred dollars and ten thousand dollars or by both such imprisonment and fine.
I live ______________________________ miles N S E W (circle one) 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 231-0167 (REVISED 04-07) *Required for registration pursuant to §115.155 RSMo and §115.158 RSMo.
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