Missouri Voter Registration Application - St Louis County

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MISSOURI VOTER REGISTRATION APPLICATION – TO BE FILLED OUT ON-LINE

If filled out by hand, use pen and please print clearly.

YOUR APPLICATION WILL BE CONFIRMED BY MAIL WITHIN SEVEN (7) BUSINESS DAYS OF RECEIPT BY THE

ELECTION AUTHORITY. PLEASE CONTACT THE ELECTION AUTHORITY IF YOU DO NOT RECEIVE NOTIFICATION.

FOR OFFICE USE ONLY

NEW REGISTRATION

ADDRESS CHANGE

NAME CHANGE

REGISTRATION NO.

LAST NAME

FIRST NAME

MIDDLE NAME

SUFFIX (Check one)

JR.

SR.

III

MALE

FEMALE

ADDRESS WHERE YOU LIVE (HOUSE NO., STREET, APT. OR RURAL RT AND BOX-NO PO BOXES)

CITY

COUNTY

ZIP CODE

ADDRESS WHERE YOU GET YOUR MAIL (IF DIFFERENT FROM #3 ABOVE)

CITY

STATE

ZIP CODE

LAST FOUR DIGITS OF SOCIAL SECURITY NO*

DATE OF BIRTH

PLACE OF BIRTH

DAYTIME PHONE NO.

(REQUIRED)

(OPTIONAL)

NAME AND ADDRESS ON LAST VOTER REGISTRATION**

Yes

ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA?

Yes

WILL YOU BE 18 YEARS OF AGE ON OR BEFORE ELECTION DAY?

NAME_______________________________________________________________

ADDRESS ___________________________________________________________

convicted of a felony or misdemeanor connected with the right of

I hereby certify that I am a citizen of the United States and a resident of Missouri. I am at

least seventeen and one half years of age. I have not been adjudged incapacitated by any

suffrage, I have had the voting disabilities from such a conviction

CITY ______________________________________________ STATE __________

court of law. If I have been convicted of a felony or misdemeanor connected with the right

removed pursuant to law. I swear under penalty of perjury that all

of suffrage, I have had the voting disabilities from such a conviction removed pursuant to

COUNTY _________________________

statements made on this card are true to the best of my knowledge

law. I swear under penalty of perjury that all statements made on this card are true to the

and belief.

** If currently registered in another state please complete this box

best of my knowledge and belief.

RURAL VOTERS: COMPLETE THIS SECTION IF YOU LIVE OUTSIDE THE CITY

LIMITS OF ANY CITY.

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.

Required for registration pursuant to §115.155 RSMo. and will be used only by authorized officials to combat voter fraud and facilitate orderly elections

See next page for voter registration and mailing instructions