MISSISSIPPI VOTER REGISTRATION APPLICATION

Transcription

1 MISSISSIPPI VOTER REGISTRATION APPLICATION IMPORTANT! If you are not registered to vote where you now live, you can use this form to register to vote or report that your name or address has changed. If you have questions call your county Circuit Clerk or call the Secretary of State at Complete all sections of this form, then mail or hand deliver it to your county Circuit Clerk AT LEAST 30 days before the election in which you want to vote. If you are qualified and the information on your form is complete, you will be mailed a voter card that tells you where to vote. Section I. APPLICATION TO REGISTER TO VOTE Please select one of the following: New Registration Change of Information 1) Are you a citizen of the United States of America? Yes No NOTE: If you checked No in response to 2) Will you be 18 years of age on or before Election Day? Yes No questions 1 or 2, do not complete this form. 3) Would you like to serve as an Election Day Poll Worker? Yes No CIRCLE Last Name: First Name: Middle/Maiden Name: Suffix: (JR, II) Mr. Mrs. Miss Ms. Physical Home Address (Number & Street/Road/Dorm/Apt. or Lot #): City: County: State: MS Zip: Mailing Address (if different from above, include zip code): Date of Birth: Mississippi Driver s License Number (If you do not have a driver s license, then list the last 4 digits of your Social Security Number): *** ***Identification Requirement: If you do not have a driver s license or social security number, and this form is submitted by mail, and you have never registered to vote in the county you are now registering in, you must send, with this application, either a) a copy of current and valid photo identification, or b) a copy of a current utility bill, bank statement, government check, paycheck, or other government document that shows the name and address of the voter. If you do not provide the information requested above, you may be required to provide to election officials either (a) or (b) above the first time you vote after January 1, 2004 at a voting place or by absentee ballot. Section II. IF YOU WERE PREVIOUSLY REGISTERED UNDER A DIFFERENT NAME OR ADDRESS, LIST THAT NAME OR ADDRESS CIRCLE Mr. Mrs. Miss Ms. Last Name: First Name: Middle/Maiden Name: Suffix: (JR, II) Previous Address (Number & Street/Road/Dorm/Apt. or Lot #): Previous City: Previous County: Previous State: Previous Zip: Section III. VOTER DECLARATION- Read and Sign I swear/affirm that: I am a U.S. citizen. I will have lived in this state and county for at least 30 days before voting, and if a resident of a municipality, I will have lived in the municipality for at least 30 days before voting. I have never been convicted of murder, arson, armed robbery, bigamy, bribery, embezzlement, extortion, felony bad check, felony shoplifting, forgery, larceny, obtaining money or goods under false pretense, perjury, rape, receiving stolen property, robbery, theft, timber larceny, unlawful taking of a motor vehicle, statutory rape, or carjacking, or I have had my rights restored as required by law. I have not been declared mentally incompetent by a court. Furthermore, I certify that I am at least eighteen (18) years old (or I will be before the next general election), the information given by me is true and correct and that I have truly answered all questions on this application for registration, and 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. X Signature (or mark) of applicant X If applicant is unable to sign, the person who assisted the applicant must sign above Daytime phone number(s) where applicant can be reached Date: Date: WARNING: False registration is a felony. The penalty for conviction of false registration is imprisonment for not more than five (5) years or a fine of not more than five thousand dollars ($5000), or both. 07/2004

2 Circuit Court Clerks December 18, 2014 Adams County Circuit Clerk Edward C. Walker P.O. Box 1224 Natchez, MS Phone: Fax: Alcorn County Circuit Clerk Joe Caldwell P.O. Box 430 Corinth, MS Phone: Fax: Amite County Circuit Clerk Debbie Kirkland P.O. Box 312 Liberty, MS Phone: Fax: Attala County Circuit Clerk Wanda Fancher 100 Courthouse, Ste 1 Kosciusko, MS Phone: Fax: Benton County Circuit Clerk Kathy M. Graves P.O. Box 262 Ashland, MS Phone: Fax: Bolivar County Circuit Clerk Marilyn L. Kelly P.O. Box 205 Rosedale, MS Phone: Fax: Marilyn L. Kelly P.O. Box 670 Cleveland, MS Phone: Fax: Calhoun County Circuit Clerk Carlton Baker P.O. Box 25 Pittsboro, MS Phone: Fax: Carroll County Circuit Clerk Durward Stanton P.O. Box 60 Carrollton, MS Phone: Fax: Durward Stanton P.O. Box 6 Vaiden, MS Phone: Fax: Chickasaw County Circuit Clerk Cassandra Pulliam 1 Pinson Square, Room 2 Houston, MS Phone: Fax: Cassandra Pulliam 234 W. Main Street, Room 203 Okolona, MS Phone: Fax: Choctaw County Circuit Clerk Peggy Miller P.O. Box 34 Ackerman, MS Phone: Fax:

3 Claiborne County Circuit Clerk Sammie Lee Good P.O. Box 549 Port Gibson, MS Phone: Fax: Clarke County Circuit Clerk Beth Doggett Jordan P.O. Box 216 Quitman, MS Phone: Fax: Clay County Circuit Clerk Bob Harrell P.O. Box 364 West Point, MS Phone: Fax: Coahoma County Circuit Clerk Charles A. Oakes P.O. Drawer 849 Clarksdale, MS Phone: Fax: Copiah County Circuit Clerk Edna E. Stevens P.O. Box 467 Hazlehurst, MS Phone: Fax: Covington County Circuit Clerk Melissa Duckworth P.O. Box 667 Collins, MS Phone: Fax: Desoto County Circuit Clerk Dale K. Thompson 2535 Hwy 51 S, Rm 201 Hernando, MS Phone: Fax: Forrest County Circuit Clerk Lou Ellen Adams P.O. Drawer 992 Hattiesburg, MS Phone: Fax: Franklin County Circuit Clerk Millie Thornton P.O. Box 267 Meadville, MS Phone: Fax: George County Circuit Clerk Chad Welford 355 Cox St., Ste C Lucedale, MS Phone: Fax: Greene County Circuit Clerk Cecelia Bounds P.O. Box 310 Leakesville, MS Phone: Fax: Grenada County Circuit Clerk Linda M. Barnette P.O. Box 1517 Grenada, MS Phone: Fax: Hancock County Circuit Clerk Karen Ladner Ruhr 3068 Longfellow Dr. Bld 7 Bay St. Louis, MS Ph.: Fax: Harrison County Circuit Clerk Gayle Parker P.O. Box 998 Gulfport, MS Phone: Fax: Gayle Parker P.O. Box 235 Biloxi, MS Phone: Fax:

4 Hinds County Circuit Clerk Barbara Dunn P.O. Box 327 Jackson, MS Phone: Fax: Barbara Dunn P.O. Box 999 Raymond, MS Phone: Fax: Holmes County Circuit Clerk Earline Wright-Hart P.O. Box 718 Lexington, MS Phone: Fax: Humphreys County Circuit Clerk Timaka J. Jones P.O. Box 696 Belzoni, MS Phone: Fax: Issaquena County Circuit Clerk Earline Fortner P.O. Box 27 Mayersville, MS Phone: Fax: Itawamba County Circuit Clerk Carol Gates 201 West Main Street Fulton, MS Phone: Fax: Jackson County Circuit Clerk Joe W. Martin, Jr. P.O. Box 998 Pascagoula, MS Phone: Fax: Jasper County Circuit Clerk Billy G. Rayner P.O. Box 58 Paulding, MS Phone: Fax: Billy G. Rayner P.O. Box 447 Bay Springs, MS Phone: Fax: Jefferson County Circuit Clerk Arnell Harried P.O. Box 305 Fayette, MS Phone: Fax: Jefferson Davis County Circuit Clerk Clint W. Langley P.O. Box 1090 Prentiss, MS Phone: Fax: Jones County Circuit Clerk Wendell Bart Gavin, Jr. 101 Court Street, Suite B Ellisville, MS Phone: Fax: Wendell Bart Gavin, Jr. P.O. Box 1336 Laurel, MS Phone: Fax: Kemper County Circuit Clerk Tracey Murray P.O. Box 130 DeKalb, MS Phone: Fax: Lafayette County Circuit Clerk

5 Baretta J. Mosley 1 Courthouse Square, Ste 101 Oxford, MS Phone: Fax: Lamar County Circuit Clerk Leslie Wilson P.O. Box 369 Purvis, MS Phone: Fax: Lauderdale County Circuit Clerk Donna Jill Johnson P.O. Box 1005 Meridian, MS Phone: Fax: Lawrence County Circuit Clerk James Sandy Brister P.O. Box 1249 Monticello, MS Phone: Fax: Leake County Circuit Clerk Kathy G. Henderson P.O. Box 67 Carthage, MS Phone: Fax: Lee County Circuit Clerk Joyce Roberts Loftin P.O. Box 762 Tupelo, MS Phone: Fax: Leflore County Circuit Clerk Elmus Stockstill P.O. Box 1953 Greenwood, MS Phone: Fax: Lincoln County Circuit Clerk Dustin Biarfield P.O. Box 357 Brookhaven, MS Phone: Fax: Lowndes County Circuit Clerk Mahala Nickles Salazar P.O. Box 31 Columbus, MS Phone: Fax: Madison County Circuit Clerk Lee Westbrook P.O. Drawer 1626 Canton, MS Phone: Fax: Marion County Circuit Clerk Janette Nolan 250 Broad Street, Suite 1 Columbia, MS Phone: Fax: Marshall County Circuit Clerk Lucy Carpenter P.O. Box 459 Holly Springs, MS Phone: Fax: Monroe County Circuit Clerk Judy K. Butler P.O. Box 843 Aberdeen, MS Phone: Fax: Montgomery County Circuit Clerk Lanelle Garrett Martin P.O. Box 765 Winona, MS Phone: Fax: Neshoba County Circuit Clerk Patti Duncan Lee 401 E. Beacon St., Ste 110 Philadelphia, MS Phone: Fax:

6 Newton County Circuit Clerk Mike Butler P.O. Box 447 Decatur, MS Phone: Fax: Noxubee County Circuit Clerk Freda Phillips 505 South Jefferson Macon, MS Phone: Fax: Oktibbeha County Circuit Clerk Glenn Hamilton 108 W. Main Street Starkville, MS Phone: Fax: Panola County Circuit Clerk Melissa Meek Phelps 215 Pocahontas Street Sardis, MS Phone: Fax: Melissa Meek Phelps P.O. Box 346 Batesville, MS Phone: Fax: Pearl River County Circuit Clerk Vicki P. Hariel 200 South Main Street Poplarville, MS Phone: Fax: Perry County Circuit Clerk Martha F. Clark P.O. Box 198 New Augusta, MS Phone: Fax: Pike County Circuit Clerk Roger A. Graves P.O. Box 31 Magnolia, MS Phone: Fax: Pontotoc County Circuit Clerk Melinda Nowicki P.O. Box 428 Pontotoc, MS Phone: Fax: Prentiss County Circuit Clerk Mike Kelley P. O. Box 727 Booneville, MS Phone: Fax: Quitman County Circuit Clerk Brenda A. Wiggs 220 Chestnut St., Ste 4 Marks, MS Phone: Fax: Rankin County Circuit Clerk Becky Boyd P.O. Drawer 1599 Brandon, MS Phone: Fax: Scott County Circuit Clerk Joe Rigby P.O. Box 371 Forest, MS Phone: Fax: Sharkey County Circuit Clerk Murindia Williams P.O. Box 218 Rolling Fork, MS Phone: Fax:

7 Simpson County Circuit Clerk Cindy M. Jensen P.O. Box 307 Mendenhall, MS Phone: Fax: Smith County Circuit Clerk Anthony Grayson P.O. Box 517 Raleigh, MS Phone: Fax: Stone County Circuit Clerk Kenny Hatten 323 Cavers Avenue Wiggins, MS Phone: Fax: Sunflower County Circuit Clerk Sharon McFadden P.O. Box 880 Indianola, MS Phone: Fax: Tallahatchie County Circuit Clerk Stephanie D. Sims P.O. Box 86 Charleston, MS Phone: Fax: Stephanie D. Sims P.O. Box 96 Sumner, MS Phone: Fax: Tate County Circuit Clerk Edward Hadskey 201 Ward Street Senatobia, MS Phone: Fax: Tippah County Circuit Clerk Randy Graves 102-A North Main Ripley, MS Phone: Fax: Tishomingo County Circuit Clerk Donna Henry Dill 1008 Battleground Iuka, MS Phone: Fax: Tunica County Circuit Clerk Sharon Granberry Reynolds P.O. Box 184 Tunica, MS Phone: Fax: Union County Circuit Clerk Phyllis Stanford P.O. Box 298 New Albany, MS Phone: Fax: Walthall County Circuit Clerk Vernon E. Alford 200 Ball Avenue Tylertown, MS Phone: Fax: Warren County Circuit Clerk Jan Hyland Daigre P.O. Box 351 Vicksburg, MS Phone: Fax:

8 Washington County Circuit Clerk Barbara Esters Parker P.O. Box 1276 Greenville, MS Phone: Fax: Wayne County Circuit Clerk Rose M. Bingham 609 Azalea Waynesboro, MS Phone: Fax: Webster County Circuit Clerk Deborah Hood Neal P.O. Box 308 Walthall, MS Phone: Fax: Wilkinson County Circuit Clerk Lynn Tolliver-Delaney P.O. Box 327 Woodville, MS Phone: Fax: Winston County Circuit Clerk Kim T. Ming P.O. Drawer 785 Louisville, MS Phone: Fax: Yalobusha County Circuit Clerk Daryl Burney P.O. Box 260 Coffeeville, MS Phone: Fax: Daryl Burney P.O. Box 1431 Water Valley, MS Phone: Fax: Yazoo County Circuit Clerk Robert Coleman P.O. Box 108 Yazoo City, MS Phone: Fax: