Mississippi Mail-In Voter Registration Application
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1MISSISSIPPI 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
or call (844) 678-6837.
Check One:
Are you a citizen of the United States of America?
Yes □ No □
□ New
Will you be 18 years of age on or before Election Day?
Yes □ No □
Registration
NOTE: If you checked ‘No’ in response to either of these questions, DO NOT complete this form.
□ Change of
Would you like to serve as an Election Day poll worker?
Yes □ No □
Information
Last Name
First Name
MI
Suffix
Name
Number and Street/Road/Dorm/Apt #
Physical Home
Address
City
County
State:
Zip
(Where you live)
MS
Street or Post Office Box
Mailing Address
(If different from
City
County
State:
Zip
above)
MS Driver’s License
Month
Day
Year
Date of Birth
_______________________
Number or Last 4
Digits of your Social
or
Home
Work
Phone #
Security Number
(
)
(
)
___ ___ ___ ___
Name
Address
Previous
Registration
City
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
08/2016
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