Mississippi Voter Registration Application Form
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SWORN WRITTEN APPLICATION FOR REGISTRATION
(By reason of the provisions of Sections 241,241-A and 244 of the Constitution of Mississippi and its relevant statutes of the State of Mississippi, the applicant for registration, if not physically disabled is required to fill in this form in his own handwriting in the presence of the registrar and without assistance or suggestion of any person or memorandum.)
1. Write the date of this application .
2. What is your full name...............................................................?
3. State you age and date of birth .
4. What is your occupation?
5. Where is your business carried on? (Give city, town or village, and street address, if any, but if none, post office address.) if not engaged in business, so state ..
6. By whom are you employed? (Give name and street address, if any, but if none, post office address.) if not employed, so state .
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7. Where is your place of residence in the county and district where you propose to register? (Give city, town or village, and street address, is any, but if none, post office address.)
8. Are you a citizen of the United States and an inhabitant of Mississippi?.............
9. How long have you resided in Mississippi?..........................
10. How long have you resided in the election district or precinct in which you propose to register?.................................
11. State your last previous places of residence. (Give street address, if any, but if none, post office address.) ..
12. Are you a minister of the gospel in charge of an organized church, or the wife of such a minister? If so, what church? (Give address in each instance.) .
13. Check which oath you desire to take: (1) General (2) Ministers (3) Ministers wife ..(4) if under 21 years at present, but will be 21 years old by date of general election .
14. If there is more than one person of your same name in the precinct, by what name do you wish to be called?..................................................................
15. Have you ever been convicted of any of the following crimes: bribery, theft, arson, obtaining money or goods under false pretenses, perjury, forgery, embezzlement, or bigamy?...................................................................................
16. Have you ever been convicted of any other crime (excepting misdemeanors for traffic violations)?...............................................................................
17. If your answer to question 15 or 16 is Yes, name the crime or crimes of which you have been convicted, and the year, court, and place of such conviction or convictions: .
18. Write and copy in the space below, Section ..of the Constitution of Mississippi; (Instructions to Registrar: You will designate the Section of the Constitution and point out same to applicant)
19. Write in the space below a reasonable interpretation (the meaning) of the Section of the Constitution of Mississippi which you have just copied
20. Write in the space below a statement setting forth your understanding of the duties and obligations of citizenship under a constitutional form of government .
21. Sign the oath or affirmation referred to in question 13, and which is:
Note: Registrar give applicant oath selected under question 13, Mark out that portion of oath that is not applicable.
Note: Registrar. In registering voters in Cities and Town not all in one election district, the name of such city or town may be substituted in the Oath for the Election District.
(a) General and/or Special Oath:
(b) I, ., do solemnly swear (or affirm) that I am twenty-one years old (or I will be before the next election in this County) and that I will have resided in this State two years, and .Election District or ..County one year next preceding the ensuing election, and am now in good faith a resident of the same, and that I am not disqualified from voting by reason of having been convicted of any crime named in the Constitution of this State as a disqualification to be an elector; that I will truly answer all questions propounded to me concerning my antecedents so far as they relat3e to my right to vote, and also as to my residence before my citizenship in this District; that I will faithfully support the Constitution of the United States and the State of Mississippi, and will bear true faith and allegiance to the same, So Help Me God.
Applicants Signature to Oath
(c) Oath of Minister and /or Ministers Wife
I, ., do solemnly swear (or affirm) that I am twenty-one years old (or I will be before the next election in this County) and that I am a Minister, or the wife of a Minister, of the Gospel in charge of an organized church, and that I will have resided two years in this State and in Election District of County six months next preceding the ensuing election, and am now in good faith a resident of the same, and that I am not disqualified from voting by reason of having been convicted of any crime named in the Constitution of this State as a disqualification to be an elector: that I will truly answer all questions propounded to me concerning my antecedents so far as they relate to my right to vote, and also as to my residence before my citizenship in this District; that I will faithfully support the Constitution of the United States and of the State of Mississippi, and will bear true faith and allegiance to the same, So Help Me God.
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Applicants Signature to Oath
Applicants Signature to Application
(The Applicant will also sign his name here)
State of Mississippi
County of
Sworn to and subscribed before me by the within named .on
This the ..day of , 19 ..
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County Registrar
(Seal)
Is applicant of good moral character?................................
If not, why?........................................................................................................................................................................
Does applicant qualify?.....................................................
Passed Failed ..