Sworn to (or affirmed) and subscribed before U.S. Office of Personnel Management + August 1965 Back Do not write on this side-for 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? Yes No Write in his date of birth 4. If applicant shows that he has not lived in Georgia for one year, will he have lived in Georgia for one year by the date of the next election? Yes No If yes, write in date residence 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 election? 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? Yes No 8. (a) If applicant shows that he is now registered 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? 13. Are you now living in a charitable home or institution? Yes No 14. What is your political party preference? 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 will faithfully and fully abide by all of the laws of the State of Louisiana, that I am well disposed to the good order and happiness of the State of Louisiana and of the United States, and that the information I have provided is true to the best of my knowledge and belief. Signature (or mark) of applicant Sworn to (or affirmed) and subscribed before me this date Examiner U.S. Office of Personnel Management CSC Form 805-L + August 1965 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? 11. If applicant answers yes, write in whether dishonorably discharged or a deserter? If dishonorably discharged, has he been reinstated? Yes No If yes, when and where? If a deserter, has he returned to his command and made up his lost time? 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 EXAMINER 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 pre cinct 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 State of Mississippi, and will bear true faith and allegiance to the same. So help me God. Signature (or mark) of applicant Sworn to (or affirmed) and subscribed before me this date Examiner U.S. Office of Personnel Management Certificate of Eligibility Issued-No. Notice of Ineligibility Issued-No. CSC Form 805-M Revised February 1973 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 Yes No (b) Are you now listed under the Voting Rights Act Yes No 10. Are you a citizen of the United States and the State of South Carolina Certificate of eligibility issued-No. Notice of ineligibility issued-No. TEXAS Front Form approved OMB No. 50R0592 Voting Rights Act Application The information requested below is for the purpose of determining whether you are eligible to vote. If you are found eligible to vote, your name will be certified to appropriate state officials for addition to the official voting lists. The solicitation of this information for this purpose is authorized by the Voting Rights Act of 1965, as amended. While you are not required to respond, your cooperation is needed if you wish to be found eligible to vote. 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. |