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 1-800-829-6786. 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
Circuit Court Clerks December 18, 2014 Adams County Circuit Clerk Edward C. Walker P.O. Box 1224 Natchez, MS 39121-1224 Phone: 601-446-6326 Fax: 601-445-7955 Alcorn County Circuit Clerk Joe Caldwell P.O. Box 430 Corinth, MS 38835 Phone: 662-286-7740 Fax: 662-286-7767 Amite County Circuit Clerk Debbie Kirkland P.O. Box 312 Liberty, MS 39645 Phone: 601-657-8932 Fax: 601-657-1082 Attala County Circuit Clerk Wanda Fancher 100 Courthouse, Ste 1 Kosciusko, MS 39090 Phone: 662-289-1471 Fax: 662-289-7666 Benton County Circuit Clerk Kathy M. Graves P.O. Box 262 Ashland, MS 38603 Phone: 662-224-6310 Fax: 662-224-6312 Bolivar County Circuit Clerk Marilyn L. Kelly P.O. Box 205 Rosedale, MS 38769 Phone: 662-759-6521 Fax: 662-759-3717 Marilyn L. Kelly P.O. Box 670 Cleveland, MS 38732 Phone: 662-843-2061 Fax: 662-846-2943 Calhoun County Circuit Clerk Carlton Baker P.O. Box 25 Pittsboro, MS 38951 Phone: 662-412-3101 Fax: 662-412-3103 Carroll County Circuit Clerk Durward Stanton P.O. Box 60 Carrollton, MS 38917 Phone: 662-237-9274 Fax: 662-237-9642 Durward Stanton P.O. Box 6 Vaiden, MS 39176 Phone: 662-464-5476 Fax: 662-464-5407 Chickasaw County Circuit Clerk Cassandra Pulliam 1 Pinson Square, Room 2 Houston, MS 38851 Phone: 662-456-2331 Fax: 662-456-4831 Cassandra Pulliam 234 W. Main Street, Room 203 Okolona, MS 38860 Phone: 662-447-2838 Fax: 662-447-5024 Choctaw County Circuit Clerk Peggy Miller P.O. Box 34 Ackerman, MS 39735 Phone: 662-285-6245 Fax: 662-285-2196
Claiborne County Circuit Clerk Sammie Lee Good P.O. Box 549 Port Gibson, MS 39150 Phone: 601-437-5841 Fax: 601-437-4543 Clarke County Circuit Clerk Beth Doggett Jordan P.O. Box 216 Quitman, MS 39355 Phone: 601-776-3111 Fax: 601-776-1001 Clay County Circuit Clerk Bob Harrell P.O. Box 364 West Point, MS 39773 Phone: 662-494-3384 Fax: 662-495-2057 Coahoma County Circuit Clerk Charles A. Oakes P.O. Drawer 849 Clarksdale, MS 38614 Phone:662-624-3014 Fax:662-624-3075 Copiah County Circuit Clerk Edna E. Stevens P.O. Box 467 Hazlehurst, MS 39083 Phone: 601-894-1241 Fax: 601-894-3026 Covington County Circuit Clerk Melissa Duckworth P.O. Box 667 Collins, MS 39428 Phone: 601-765-6506 Fax: 601-765-5012 Desoto County Circuit Clerk Dale K. Thompson 2535 Hwy 51 S, Rm 201 Hernando, MS 38632 Phone: 662-429-1325 Fax: 662-449-1416 Forrest County Circuit Clerk Lou Ellen Adams P.O. Drawer 992 Hattiesburg, MS 39403 Phone: 601-582-3213 Fax: 601-545-6065 Franklin County Circuit Clerk Millie Thornton P.O. Box 267 Meadville, MS 39653 Phone: 601-384-2320 Fax: 601-384-8244 George County Circuit Clerk Chad Welford 355 Cox St., Ste C Lucedale, MS 39452 Phone: 601-947-4881 Fax: 601-947-8804 Greene County Circuit Clerk Cecelia Bounds P.O. Box 310 Leakesville, MS 39451 Phone: 601-394-2379 Fax: 601-394-2334 Grenada County Circuit Clerk Linda M. Barnette P.O. Box 1517 Grenada, MS 38902-1517 Phone: 662-226-1941 Fax: 662-227-2865 Hancock County Circuit Clerk Karen Ladner Ruhr 3068 Longfellow Dr. Bld 7 Bay St. Louis, MS 39520 Ph.: 228-467-5265 Fax: 228-467- 2779 Harrison County Circuit Clerk Gayle Parker P.O. Box 998 Gulfport, MS 39502 Phone: 228-865-4051 Fax: 228-865-4099 Gayle Parker P.O. Box 235 Biloxi, MS 39533 Phone: 228-435-8233 Fax: 228-435-8270
Hinds County Circuit Clerk Barbara Dunn P.O. Box 327 Jackson, MS 39205 Phone: 601-968-6628 Fax: 601-973-5547 Barbara Dunn P.O. Box 999 Raymond, MS 39154 Phone: 601-857-8038 Fax: 601-857-0535 Holmes County Circuit Clerk Earline Wright-Hart P.O. Box 718 Lexington, MS 39095 Phone: 662-834-2476 Fax: 662-834-3870 Humphreys County Circuit Clerk Timaka J. Jones P.O. Box 696 Belzoni, MS 39038 Phone: 662-247-3065 Fax: 662-247-3906 Issaquena County Circuit Clerk Earline Fortner P.O. Box 27 Mayersville, MS 39113 Phone: 601-873-2761 Fax: 601-873-2061 Itawamba County Circuit Clerk Carol Gates 201 West Main Street Fulton, MS 38843 Phone: 662-862-3511 Fax: 662-862-4006 Jackson County Circuit Clerk Joe W. Martin, Jr. P.O. Box 998 Pascagoula, MS 39568 Phone: 228-769-3040 Fax: 228-769-3180 Jasper County Circuit Clerk Billy G. Rayner P.O. Box 58 Paulding, MS 39348 Phone: 601-727-4941 Fax: 601-727-4475 Billy G. Rayner P.O. Box 447 Bay Springs, MS 39422 Phone: 601-764-2245 Fax: 601-764-3078 Jefferson County Circuit Clerk Arnell Harried P.O. Box 305 Fayette, MS 39069 Phone: 601-786-3422 Fax: 601-786-9676 Jefferson Davis County Circuit Clerk Clint W. Langley P.O. Box 1090 Prentiss, MS 39474 Phone: 601-792-4231 Fax: 601-792-4957 Jones County Circuit Clerk Wendell Bart Gavin, Jr. 101 Court Street, Suite B Ellisville, MS 39437 Phone: 601-477-8538 Fax: 601-477-8539 Wendell Bart Gavin, Jr. P.O. Box 1336 Laurel, MS 39441 Phone: 601-425-2556 Fax: 601-399-4774 Kemper County Circuit Clerk Tracey Murray P.O. Box 130 DeKalb, MS 39328 Phone: 601-743-2224 Fax: 601-743-4173 Lafayette County Circuit Clerk
Baretta J. Mosley 1 Courthouse Square, Ste 101 Oxford, MS 38655 Phone: 662-234-4951 Fax: 662-236-0238 Lamar County Circuit Clerk Leslie Wilson P.O. Box 369 Purvis, MS 39475 Phone: 601-794-8504 Fax: 601-794-3905 Lauderdale County Circuit Clerk Donna Jill Johnson P.O. Box 1005 Meridian, MS 39302-1005 Phone: 601-482-9731 Fax: 601-482-9734 Lawrence County Circuit Clerk James Sandy Brister P.O. Box 1249 Monticello, MS 39654 Phone: 601-587-4791 Fax: 601-587-4405 Leake County Circuit Clerk Kathy G. Henderson P.O. Box 67 Carthage, MS 39051 Phone: 601-267-8357 Fax: 601-267-8889 Lee County Circuit Clerk Joyce Roberts Loftin P.O. Box 762 Tupelo, MS 38802 Phone:662-841-9024 Fax:662-680-6079 Leflore County Circuit Clerk Elmus Stockstill P.O. Box 1953 Greenwood, MS 38935 Phone: 662-453-1435 Fax: 662-455-1278 Lincoln County Circuit Clerk Dustin Biarfield P.O. Box 357 Brookhaven, MS 39602 Phone: 601-835-3435 Fax: 601-835-3482 Lowndes County Circuit Clerk Mahala Nickles Salazar P.O. Box 31 Columbus, MS 39703 Phone: 662-329-5900 Fax: 662-329-5935 Madison County Circuit Clerk Lee Westbrook P.O. Drawer 1626 Canton, MS 39046 Phone: 601-859-4365 Fax: 601-859-8555 Marion County Circuit Clerk Janette Nolan 250 Broad Street, Suite 1 Columbia, MS 39429 Phone: 601-736-8246 Fax: 601-731-6344 Marshall County Circuit Clerk Lucy Carpenter P.O. Box 459 Holly Springs, MS 38635 Phone: 662-252-3434 Fax: 662-252-5951 Monroe County Circuit Clerk Judy K. Butler P.O. Box 843 Aberdeen, MS 39730 Phone: 662-369-8695 Fax: 662-369-3684 Montgomery County Circuit Clerk Lanelle Garrett Martin P.O. Box 765 Winona, MS 38967 Phone: 662-283-4161 Fax: 662-283-3363 Neshoba County Circuit Clerk Patti Duncan Lee 401 E. Beacon St., Ste 110 Philadelphia, MS 39350 Phone: 601-656-4781 Fax: 601-650-3997
Newton County Circuit Clerk Mike Butler P.O. Box 447 Decatur, MS 39327 Phone: 601-635-2368 Fax: 601-635-3210 Noxubee County Circuit Clerk Freda Phillips 505 South Jefferson Macon, MS 39341 Phone: 662-726-5737 Fax: 662-726-6041 Oktibbeha County Circuit Clerk Glenn Hamilton 108 W. Main Street Starkville, MS 39759 Phone: 662-323-1356 Fax: 662-323-1121 Panola County Circuit Clerk Melissa Meek Phelps 215 Pocahontas Street Sardis, MS 38666 Phone: 662-487-2073 Fax: 662-487-3595 Melissa Meek Phelps P.O. Box 346 Batesville, MS 38606 Phone: 662-563-6210 Fax: 662-563-8233 Pearl River County Circuit Clerk Vicki P. Hariel 200 South Main Street Poplarville, MS 39470 Phone: 601-403-2300 Fax: 601-403-2327 Perry County Circuit Clerk Martha F. Clark P.O. Box 198 New Augusta, MS 39642 Phone: 601-964-8663 Fax: 601-964-8740 Pike County Circuit Clerk Roger A. Graves P.O. Box 31 Magnolia, MS 39652 Phone: 601-783-2581 Fax: 601-783-6322 Pontotoc County Circuit Clerk Melinda Nowicki P.O. Box 428 Pontotoc, MS 38863 Phone: 662-489-3908 Fax: 662-489-2318 Prentiss County Circuit Clerk Mike Kelley P. O. Box 727 Booneville, MS 38829 Phone: 662-728-4611 Fax: 662-728-2006 Quitman County Circuit Clerk Brenda A. Wiggs 220 Chestnut St., Ste 4 Marks, MS 38646 Phone: 601-326-8003 Fax: 601-326-8004 Rankin County Circuit Clerk Becky Boyd P.O. Drawer 1599 Brandon, MS 39043 Phone: 601-825-1466 Fax: 601-825-1465 Scott County Circuit Clerk Joe Rigby P.O. Box 371 Forest, MS 39074 Phone: 601-469-3601 Fax: 601-469-5188 Sharkey County Circuit Clerk Murindia Williams P.O. Box 218 Rolling Fork, MS 39159 Phone: 601-873-2755 Fax: 601-873-6045
Simpson County Circuit Clerk Cindy M. Jensen P.O. Box 307 Mendenhall, MS 39114 Phone: 601-847-2474 Fax: 601-847-4011 Smith County Circuit Clerk Anthony Grayson P.O. Box 517 Raleigh, MS 39153 Phone: 601-782-4751 Fax: 601-782-4007 Stone County Circuit Clerk Kenny Hatten 323 Cavers Avenue Wiggins, MS 39577 Phone: 601-928-5246 Fax: 601-928-5248 Sunflower County Circuit Clerk Sharon McFadden P.O. Box 880 Indianola, MS 38751 Phone: 662-887-1252 Fax: 662-887-7077 Tallahatchie County Circuit Clerk Stephanie D. Sims P.O. Box 86 Charleston, MS 38921 Phone: 662-647-8758 Fax: 662-647-8490 Stephanie D. Sims P.O. Box 96 Sumner, MS 38957 Phone: 662-375-8515 Fax: 662-375-7252 Tate County Circuit Clerk Edward Hadskey 201 Ward Street Senatobia, MS 38868 Phone: 662-562-5211 Fax: 662-562-7486 Tippah County Circuit Clerk Randy Graves 102-A North Main Ripley, MS 38663 Phone: 662-837-7370 Fax: 662-837-1030 Tishomingo County Circuit Clerk Donna Henry Dill 1008 Battleground Iuka, MS 38852 Phone: 662-423-7026 Fax: 662-423-1667 Tunica County Circuit Clerk Sharon Granberry Reynolds P.O. Box 184 Tunica, MS 38676 Phone: 662-363-2842 Fax: 662-363-2413 Union County Circuit Clerk Phyllis Stanford P.O. Box 298 New Albany, MS 38652 Phone: 662-534-1910 Fax: 662-534-2059 Walthall County Circuit Clerk Vernon E. Alford 200 Ball Avenue Tylertown, MS 39667 Phone: 601-876-5677 Fax: 601-876-4077 Warren County Circuit Clerk Jan Hyland Daigre P.O. Box 351 Vicksburg, MS 39181 Phone: 601-636-3961 Fax: 601-630-4100
Washington County Circuit Clerk Barbara Esters Parker P.O. Box 1276 Greenville, MS 38702 Phone: 662-378-2747 Fax: 662-334-2698 Wayne County Circuit Clerk Rose M. Bingham 609 Azalea Waynesboro, MS 39367 Phone: 601-735-1171 Fax: 601-735-6261 Webster County Circuit Clerk Deborah Hood Neal P.O. Box 308 Walthall, MS 39771 Phone: 601-258-6287 Fax: 601-258-7686 Wilkinson County Circuit Clerk Lynn Tolliver-Delaney P.O. Box 327 Woodville, MS 39669 Phone: 601-888-6697 Fax: 601-888-6984 Winston County Circuit Clerk Kim T. Ming P.O. Drawer 785 Louisville, MS 39339 Phone: 662-773-3581 Fax: 662-773-7192 Yalobusha County Circuit Clerk Daryl Burney P.O. Box 260 Coffeeville, MS 38922 Phone: 662-675-8187 Fax: 662-675-8004 Daryl Burney P.O. Box 1431 Water Valley, MS 38965 Phone: 662-473-1341 Fax: 662-473-5020 Yazoo County Circuit Clerk Robert Coleman P.O. Box 108 Yazoo City, MS 39194 Phone: 662-746-1872 Fax: 662-716-0113