Any wilfull false statement on this application is a Federal crime punishable by fine or imprisonment.

STOP HERE. TAKE THE FORM TO THE
EXAMINER

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

Examiner

United States Civil Service Commission CSC Form 805-A † August 1965

ALABAMA Back

Do not write on this side-for use by

examiner

ADDITIONAL INFORMATION ITEMS

2. If applicant shows his age to be under 21, write in his date of birth

Yes No

Yes No

or city for four months? If yes, write in the date residence began_--_. Former Address__ 7. If applicant's answer is yes, is his residence in Louisiana and in his parish for temporary purposes only?__.

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..

Yes No

(First) (Middle) (Last)

Any willful false statement on this application is a Federal crime punishable by fine or imprisonment.

STOP HERE. TAKE THE FORM TO THE
EXAMINER.

I do solemnly swear (or affirm) that I am now in good faith a resident of this State, my election district, and my city or town (if any); that the information I have proIvided is true and correct to the best of my knowledge, information, and belief; 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. So help me God.

In addition, if applicant is a minister or the wife of a minister of the Gospel in charge of an organized church, have him (or her) also swear to or affirm that fact. In such instances it shall be sufficient if the applicant swears or affirms that he (or she) has resided for six months (instead of one year) in the election district or city or town. Signature (or mark) of applicant-

Sworn to (or affirmed) and subscribed before me this date____.

6. If applicant shows that
he has not lived at his
present address one year,
will he by the date of the
next election have:
Lived in the same elec-
tion district for one year?
If applicant is a minister
or minister's wife, for 6
months?

If yes, write in the date
residence began----
Former address__

Lived in the same city,
town, or village for one
year?

If applicant is a minister
or minister's wife, for 6
months?

If yes, write in the date
residence began...--
Former address___

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 un-
der 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 pre-
tenses?

If yes, answer the follow-
ing questions:

Which crime?_.

When and where convicted?___

Yes No

Yes No

Yes No

Yes No

Yes No

Has right to vote been restored by the legislature?

If so restored, when?----11. If applicant answers yes,

has he subsequently been
declared legally sane or

competent by a court?--Yes No If yes, when and by what court?---Certificate of Eligibility Issued-No.----. Notice of Ineligibility Issued-No.----