MISSOURI VOTER REGISTRATION APPLICATION
Use this application to:
Box 5 -- Home Address
1. Register to vote in any election in Missouri.
List your home address. DO NOT put your mailing address if it differs from your
2. Register to vote when you move from one jurisdiction (St. Louis City, Kansas
home address.
City, or any county) to another jurisdiction (St. Louis City, Kansas City, or any
county) within Missouri.
Box 6 -- Mailing Address
3. Change the address on a current voter registration when you move within a
If you get your mail at an address other than your home address in Box 5, put that
jurisdiction.
address here in this box.
4. Change the name on a current voter registration.
Box 7 -- Driver’s License Number
Other information:
Required for registration unless you do not have a Driver’s License. (§115.158,
1. You must be 18 years of age by the day of a particular election to be eligible to
RSMo.) If you do not have a Driver’s License, leave blank.
vote in that election.
2. If mailed, this form must be postmarked by the 4th Wednesday preceding an
Box 8 -- Last Four Digits of Social Security Number
election to be eligible to vote in that election. If delivered in person, it must be
received in the office of the election authority by the 4th Wednesday preceding an
Required for registration unless you do not have a Social Security Number.
election. (See reverse for election calendar.)
(§115.155, RSMo, §115.158, RSMo.) If you do not have a Social Security Number,
3. Submitting this application to an individual other than the election authority
leave blank.
does not insure timely voter registration.
4. After the election authority receives your voter registration application, you will be
Box 9 -- Date of Birth
sent confirmation within 7 business days. If you do not receive confirmation,
Place your date of birth in this box (Month, Day, Year). DO NOT USE TODAY’S DATE!
contact the election authority.
5. If you wish to serve as an election judge on election day please contact your
Box 10 -- Place of Birth (Optional)
local election authority and mark the box at the bottom of this form.
List your place of birth (city/county/state).
6. Optional—If registering by mail for the first time, please submit a copy of one of
the following forms of identification: current or valid photo ID, current utility bill,
Box 11 -- Daytime Phone Number (Optional)
bank statement, government check, paycheck or other government document
Please list a number at which the election authority may contact you for clarification
that shows your name and address, birth certificate, Native American tribal
of information.
document or other proof of United States citizenship. (You will be required to
present identification when you vote.)
Box 12 -- Last Voter Registration Information
Completing this form (All information is required unless indicated as optional):
If you are currently registered, please list the name and address of your last regis-
Boxes 1 and 2 -- Citizen and Age Requirements
tration including county and state.
Federal Law requires voter registration applicants to answer these two questions.
Box 13 -- Signature
Box 3 -- Type of Application
Review the information. If you meet the requirements and all is correct, sign your
Check appropriate box if this is a new registration or if you are changing a name or
full name or make your mark and print today’s date.
address on your current voter registration.
Box 14 -- Rural Voters
Box 4 -- Name
If you live in a rural area without a street address, please supply information which
Put in this box your full name (Last, First, Middle). DO NOT use nicknames or initials.
For name changes, Box 12 should contain your old name.
may help in placing you in the proper voting district.
YOUR APPLICATION WILL BE CONFIRMED BY MAIL WITHIN SEVEN (7) BUSINESS DAYS OF ITS RECEIPT BY THE
ELECTION AUTHORITY. PLEASE CONTACT THE ELECTION AUTHORITY IF YOU DO NOT RECEIVE NOTIFICATION.
(DETACH HERE - KEEP TOP PORTION FOR YOUR RECORDS) This card is not proof of registration.
Once you have completed this application, please mail it in an
MISSOURI VOTER REGISTRATION APPLICATION
envelope with postage to your local election authority.
USE PEN - PLEASE PRINT CLEARLY
PC
1
2
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
If you checked no in response to either of the above questions, do not complete this form.
3
NEW REGISTRATION
ADDRESS CHANGE
NAME CHANGE
FOR OFFICE USE ONLY REGISTRATION NO.
4
LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
MALE
FEMALE
JR.
SR.
II
III
IV
5
ADDRESS WHERE YOU LIVE (HOUSE NO., STREET, APT. NO. OR RURAL ROUTE AND BOX - NO PO BOXES)
CITY
COUNTY
ZIP CODE
6
ADDRESS WHERE YOU GET YOUR MAIL (REQUIRED IF DIFFERENT FROM #5 ABOVE)
CITY
STATE
ZIP CODE
7
DRIVER’S LICENSE NUMBER
8
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER*
IF YOU DO NOT HAVE A DRIVER’S LICENSE,
IF YOU DO NOT HAVE A SOCIAL SECURITY NUMBER, PLEASE LEAVE BLANK.
PLEASE LEAVE BLANK.
9
10
11
DATE OF BIRTH (MM/DD/YYYY)
PLACE OF BIRTH (OPTIONAL)
DAYTIME PHONE NO. (OPTIONAL)
12
13
I hereby certify that I am a citizen of the United States and a resident of the state of
NAME AND ADDRESS ON LAST VOTER REGISTRATION
Missouri. I am at least seventeen and one half years of age. I have not been adjudged
NAME
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
resulting from such conviction removed pursuant to law. I swear under penalty of
CITY
STATE
perjury 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
COUNTY
to register, I am committing a class one election offense and may be punished by
If currently registered in another state or county please complete this box.
imprisonment of not more than five years or by a fine of between two thousand five
14
RURAL VOTERS: COMPLETE THIS SECTION IF YOU LIVE OUTSIDE THE CITY LIMITS OF
hundred dollars and ten thousand dollars or by both such imprisonment and fine.
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 §115.158 RSMo.
MO 231-0169 (REVISED 04-07)
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MISSOURI VOTER REGISTRATION APPLICATION
Use this application to:
Box 5 -- Home Address
1. Register to vote in any election in Missouri.
List your home address. DO NOT put your mailing address if it differs from your
2. Register to vote when you move from one jurisdiction (St. Louis City, Kansas
home address.
City, or any county) to another jurisdiction (St. Louis City, Kansas City, or any
county) within Missouri.
Box 6 -- Mailing Address
3. Change the address on a current voter registration when you move within a
If you get your mail at an address other than your home address in Box 5, put that
jurisdiction.
address here in this box.
4. Change the name on a current voter registration.
Box 7 -- Driver’s License Number
Other information:
Required for registration unless you do not have a Driver’s License. (§115.158,
1. You must be 18 years of age by the day of a particular election to be eligible to
RSMo.) If you do not have a Driver’s License, leave blank.
vote in that election.
2. If mailed, this form must be postmarked by the 4th Wednesday preceding an
Box 8 -- Last Four Digits of Social Security Number
election to be eligible to vote in that election. If delivered in person, it must be
received in the office of the election authority by the 4th Wednesday preceding an
Required for registration unless you do not have a Social Security Number.
election. (See reverse for election calendar.)
(§115.155, RSMo, §115.158, RSMo.) If you do not have a Social Security Number,
3. Submitting this application to an individual other than the election authority
leave blank.
does not insure timely voter registration.
4. After the election authority receives your voter registration application, you will be
Box 9 -- Date of Birth
sent confirmation within 7 business days. If you do not receive confirmation,
Place your date of birth in this box (Month, Day, Year). DO NOT USE TODAY’S DATE!
contact the election authority.
5. If you wish to serve as an election judge on election day please contact your
Box 10 -- Place of Birth (Optional)
local election authority and mark the box at the bottom of this form.
List your place of birth (city/county/state).
6. Optional—If registering by mail for the first time, please submit a copy of one of
the following forms of identification: current or valid photo ID, current utility bill,
Box 11 -- Daytime Phone Number (Optional)
bank statement, government check, paycheck or other government document
Please list a number at which the election authority may contact you for clarification
that shows your name and address, birth certificate, Native American tribal
of information.
document or other proof of United States citizenship. (You will be required to
present identification when you vote.)
Box 12 -- Last Voter Registration Information
Completing this form (All information is required unless indicated as optional):
If you are currently registered, please list the name and address of your last regis-
Boxes 1 and 2 -- Citizen and Age Requirements
tration including county and state.
Federal Law requires voter registration applicants to answer these two questions.
Box 13 -- Signature
Box 3 -- Type of Application
Review the information. If you meet the requirements and all is correct, sign your
Check appropriate box if this is a new registration or if you are changing a name or
full name or make your mark and print today’s date.
address on your current voter registration.
Box 14 -- Rural Voters
Box 4 -- Name
If you live in a rural area without a street address, please supply information which
Put in this box your full name (Last, First, Middle). DO NOT use nicknames or initials.
For name changes, Box 12 should contain your old name.
may help in placing you in the proper voting district.
YOUR APPLICATION WILL BE CONFIRMED BY MAIL WITHIN SEVEN (7) BUSINESS DAYS OF ITS RECEIPT BY THE
ELECTION AUTHORITY. PLEASE CONTACT THE ELECTION AUTHORITY IF YOU DO NOT RECEIVE NOTIFICATION.
(DETACH HERE - KEEP TOP PORTION FOR YOUR RECORDS) This card is not proof of registration.
Once you have completed this application, please mail it in an
MISSOURI VOTER REGISTRATION APPLICATION
envelope with postage to your local election authority.
USE PEN - PLEASE PRINT CLEARLY
PC
1
2
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
If you checked no in response to either of the above questions, do not complete this form.
3
NEW REGISTRATION
ADDRESS CHANGE
NAME CHANGE
FOR OFFICE USE ONLY REGISTRATION NO.
4
LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
MALE
FEMALE
JR.
SR.
II
III
IV
5
ADDRESS WHERE YOU LIVE (HOUSE NO., STREET, APT. NO. OR RURAL ROUTE AND BOX - NO PO BOXES)
CITY
COUNTY
ZIP CODE
6
ADDRESS WHERE YOU GET YOUR MAIL (REQUIRED IF DIFFERENT FROM #5 ABOVE)
CITY
STATE
ZIP CODE
7
DRIVER’S LICENSE NUMBER
8
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER*
IF YOU DO NOT HAVE A DRIVER’S LICENSE,
IF YOU DO NOT HAVE A SOCIAL SECURITY NUMBER, PLEASE LEAVE BLANK.
PLEASE LEAVE BLANK.
9
10
11
DATE OF BIRTH (MM/DD/YYYY)
PLACE OF BIRTH (OPTIONAL)
DAYTIME PHONE NO. (OPTIONAL)
12
13
I hereby certify that I am a citizen of the United States and a resident of the state of
NAME AND ADDRESS ON LAST VOTER REGISTRATION
Missouri. I am at least seventeen and one half years of age. I have not been adjudged
NAME
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
resulting from such conviction removed pursuant to law. I swear under penalty of
CITY
STATE
perjury 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
COUNTY
to register, I am committing a class one election offense and may be punished by
If currently registered in another state or county please complete this box.
imprisonment of not more than five years or by a fine of between two thousand five
14
RURAL VOTERS: COMPLETE THIS SECTION IF YOU LIVE OUTSIDE THE CITY LIMITS OF
hundred dollars and ten thousand dollars or by both such imprisonment and fine.
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 §115.158 RSMo.
MO 231-0169 (REVISED 04-07)
Print
Clear
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