STOP HERE. TAKE THE FORM TO THE I do solemnly swear (or affirm) that the information I have provided is true and correct to the best of my knowledge, information, and belief. I do further personally swear (or affirm) that I will support and defend the Constitution of the United States and the Constitution of the State of Alabama; and that I do not believe in nor am I affiliated with any group or party which advocated or advocates the overthrow of the Government of the United States or of the State of Alabama by unlawful means. Signature (or mark) of Applicant Sworn to (or affirmed) and subscribed before me on this date 5. How long have you lived at the above address? 6. What is your precinct and ward? 7. Are you now (1) on active duty in the Armed Forces of the United States or the Louisiana National Guard, (2) an employee of the United States or the State of Louisiana, or (3) a seaman or college student? O Yes No 8. (a) Are you now registered to vote in Louisiana? Yes No (b) Are you now listed under the Voting Rights Act? O Yes No 9. Are you a citizen of the United States and of the State of Louisiana? □ No Yes 10. Have you ever been convicted of a crime other than a traffic or game violation? O Yes No 11. Have you ever been dishonorably discharged from or are you a deserter from the Louisiana National Guard or militia or the military service of the United States? 7. If applicant's answer is yes, is his residence in Louisiana and in his parish for temporary purposes only? ☐ Yes No If yes, write in his occupation 8. (a) If applicant shows that he is now registered to vote in Louisiana, write in the parish where he is registered: (b) If applicant shows that he is now listed under the Voting Rights Act, write in the parish where he is listed and certificate number if available 10. If applicant answers yes, name the crime Where and when convicted? Was the conviction for a disqualifying crime? Yes No If a disqualifying crime, has applicant been pardoned with express restoration of the right to vote? Yes No If so pardoned, how and when? (a) When and where declared competent by a court: 10. (a) If you have a current driver's license, state its number and the address shown thereon: (b) If you own a motor vehicle, state license tag number and the county and State in which the vehicle is registered for ad valorem and road and bridge privilege tax purposes: (c) If you filed an income tax return for the year immediately past, state the address on your most recent income tax return: (d) If you own real property, state its location: (e) If you are receiving homestead exemption on any real property, state the location of all such property: (f) If you are currently employed, state the location of the place where you actually report for work: (g) State the location of any church affiliation or location of any other religious groups of which you are a member: (h) State the location of the greater amount of your personal possessions: (i) If you have a telephone, state its location and number: 11. Do you intend to make this precinct and county your fixed habitation, for a definite or indefinite length of time, to which you intend to return whenever absent? Yes No Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. STOP HERE. TAKE THE FORM TO THE I do solemnly swear (or affirm) that I am at least eighteen (18) years old (or will be before the next election in this county), and that I am now in good faith a resident of this state and of election precinct in this county 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 have truly answered all questions propounded to me in the foregoing application for registration; and that I will faithfully support the Constitution of the United States and of the 30-164 0-89-10 8. (a) If applicant shows that he is now registered to vote in Mississippi, write in the county where he is registered (b) If applicant shows that he is now listed under the Voting Rights Act, write in the county where he is listed and certificate number if available 10. If applicant answers yes, was the conviction for bribery, burglary, theft, arson, perjury, forgery, embezzlement, bigamy, or obtaining money or goods under false pretenses? Yes No If yes, answer the following questions: When and where convicted? Has right to vote been restored by the legislature? If yes, when and by what court? Certificate of Eligibility Issued-No. Notice of Ineligibility Issued-No. SOUTH CAROLINA Front Form approved Budget Bureau No. 50-R359 APPLICATION TO BE LISTED UNDER THE State of South Carolina County of Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you. 1. Name (Middle) 2. Age 3. Address number) or town) 4. (a) Are you a minister in charge of an organized church or the spouse of such a minister O Yes No (b) Are you a teacher in a public school or the spouse of such a teacher Yes □ No 5. How long have you lived in South Carolina 6. How long have you lived at the above address 7. What is your ward and precinct 8. Are you now (1) a student, (2) a seaman, (3) an employee of the United States, or (4) on active duty in the Armed Forces of the United States Yes No 9. (a) Are you now registered to vote in South Carolina O Yes No (b) Are you now listed under the Voting Rights Act -O Yes No 10. Are you a citizen of the United States and the State of South Carolina Yes No 11. Have you ever been convicted of a crime other than a traffic violation Yes No 12. Have you ever been declared legally insane, idiotic, or mentally incompetent by a court Yes No 13. Are you a pauper receiving all your support from your county, town, or city government O Yes No Any willful false statement on this application is a Federal crime punishable by fine or imprisonment STOP HERE-TAKE THE FORM TO THE I hereby solemnly swear (or affirm) that the information I have provided is true to the best of my knowledge and belief and I so certify. Signature (or mark) of applicant |