GEORGIA-Continued
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Do not write on this sidefor use by the Examiner ADDITIONAL INFORMATION ITEMS

2. If applicant shows his
age to be under 18, will
he be 18 by the date of
the next election?___
Write in his date of birth_
4. If applicant shows that
he has not lived in Geor-
gia for one year, will he
have lived in Georgia for
one year by the date of
the next election?------
If yes, write in date resi-
dence began---
Former address_.

5. If applicant shows that
he has not lived at his
present address for six
months, will he have
lived within the same
county for six months by
the date of the next elec-
tion?

Yes

No

Yes No

-

Yes No

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

7. If applicant answers yes, is his residence in Georgia and in his county for temporary purposes only?

8. (a) If applicant shows that he is now regis

tered to vote in Georgia, 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, name the crime__. Where and when convicted?

Was the conviction for a disqualifying crime?____ If a disqualifiying crime, has applicant been pardoned?

If so pardoned, where and when?

Yes No

Yes No

Yes No

LOUISIANA-continued

5. If applicant shows that
he has not lived at his
present address for six
months, will he by the
date of the next election
have:

Lived in the same parish
for six months?___

If yes, write in the date

residence began_-
Former Address_.

Lived in this precinct for
three months?__

If yes, write in the date
residence began__.
Former Address_.

Lived in the same town
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 par-
ish for temporary pur-
poses only?___

If yes, write in his occu-
pation

8. (a) If applicant shows

that he is now reg-
istered 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...

certificate

if available__

and

2. Age

3. Address

number

10. If applicant answers yes,
name the crime_.

Where and when convicted?.
Was the conviction for a
disqualifying crime?..
If a disqualifying crime,
has applicant been par-
doned with express res-
toration of the right to
vote?

If so pardoned, how and
when?

11. If applicant answers yes,
write in whether dishon-
orably discharged or a
deserter?

If dishonorably dis-
charged, has he been re-
instated?

(RFD or Street Number)

(First) (Middle) (Last)

(Street)

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 provided 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..

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 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?

If yes, answer the following questions:

Which crime?__.

When and where convicted?_.

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.‒‒‒‒‒‒‒‒‒-

SOUTH CAROLINA-Continued
STOP HERE-TAKE THE FORM TO THE
EXAMINER

I hereby solemnly swear (or affrm) 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--.

Sworn to (or affrmed) and subscribed befor me this date_.

Examiner

U.S. Civil Service Commission

CSC Form 805-S, October 1965

SOUTH CAROLINA

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Do not write on this side—for use by examiner

ADDITIONAL INFORMATION ITEMS

5. If the applicant shows
that he has not lived in
South Carolina for one
year, will he have lived in
South Carolina for one
year by the next election
(or six months if appli-
cant is a minister in
charge of an organized
church or a teacher in a
public school, or the
spouse of either) __.

If yes, write in the date
when he began to live in
South Carolina_.

Former address_.

6. If the applicant (other than a minister, teacher,

Yes No

Yes No

Yes No

cinct for three months. Yes No If yes, write in the date

when he began to live in

the precinct--

Former address_-_.