/ [D apfroven FOR COUNTY REGISTRATION NY) ath befey GeROVED FOR CITY REGISTRATION a¢ oenen seagate 95 lo Ter~-o~ REVIEW BY COUNTY ELECTION COMMISSIONERS [J vemen recistration, PeNoInc MD" 24 Q0 Fok REVIEW BY MUNICIPAL ELECTION COMMISSIONERS 4 = APPLICATION FOR REGISTRATION “OU MAY REGEVE ASSISTANE IN FLING OUT THIS FORM FROM ANY PERGON OF VOUR CHOOSING. 1S NOT NECESSARY THAT THS FORM BE FLED out tte PRESENGE O° HE REGISTRAN HOWEVER, THE On MOST EE EXEOUIED INTHE PRESENCE OF THE REGISTRAR OM HIS DEPUTY) “BY ARE YOU A GHZEN OF THE UNITED STATES OF AMERICA? YESL_ROD Tet yo cco NO esponas {@) Wu YOU BE 18 YEARS OF AGE ON OR BEFORE ELECTION DAY? YESS NOD cussions A or 8 8 nt complet he fem nT 1S YOUR FULL NAVE, CLUDING WAIDEN NANE, I YOU HAVE ONE? 1] Wieerar OQuver LuckerrT, oR. TWAT 1S YOUR DRIVERS UGENSE NUNEE®? {FVOU DS WOT HAVE A DAVERS UCENSE THEN UST THE 2 [LAST FOUR Ww o1aTs OF YOUR SOCIAL SECURITY NUMBER. ry WHATS YqUR Daye Ur ow aT a TARE YOU A CITIZEN OF THE UNITED STATEST 4\ves_ Ono a YOR ESD SOBNGE ADREEG 0 TAGYPLAGEYOU HAVE REDOED DORN THE PRET YEAR STATNG WEN YOU VED 5 | PLACE, AND SPECIFYING THE MUNICIPALITY OF (TY, THE STREET N/ NUMBER AND/OR = DESIGNATION JRATELY | beeen Soe a oe pT SE = BSS LIEsTOvVER DR, CLARKSDALE, MS 2396/4 our (2/07 wowny [ro oar. PRESENT PREVIOUS ABORESS a MEFES Loynerey, MEWAHIS TN B8izo rou 1 [OD ‘uowny [ror 12/0 7 ron revo oRESS ret tuowr [ro » ox (UF YOU NEED ADOMONAL SPACE, USE THE BACK SIDE OF THIS FORM) YOUR PRESENT WALI ROORESST s|'P,O.D. 1000, Zt aRKSDALE, mS BSL/4+- [ARE YOU NOW A RESIDENT OF THIS STATE AND COUNTY? 7|S€ves Ono 2 Yeu noir RESOE WT THE CTY TTS OF AGH GR TOWN LOCATED WHT HS COURT VESW” OTT 8 |r ves, ove nane oF tHe rv on Tom, LAP KS DAL Fave OU EVER REGISTERED To VOTE GRFORE MAN OTHER COUNTY OM STATEY 6G GNE WHE UST RAGE OR AST THO @) PUTED s|enaswnouore nimocee MEMOH[S, SHELGY CouNTY, TN. TATE YOU EVER BEEN COWVCTED OF THE CRITE OF MURDER RAPE: REA THEFT, ARON, OBTAINING MONEY OF 00008 UNDER FALE 10] pACTENSE, PERWURY, FORGERY, enBEzzeNENT onacAMY? C) ves JNO Fre FOLLOWS GUESTIONS WAY BE ANSWERED BY YOU AT YOUR GPGN a6 ARE BOLELY FOR TE PURPOSE OF HONG W REGITERNG 11] You Te Proven pnconcr, i [sae THERE A TERED VOTERS LNT YOUR PRESENT RESIDENCE? yes Ono TF BOGE THE NAR OF EH BUH PERE. FRADCINE c LUCKETT TO YOU FAVE TELEBHONE AT YOUR PRESENT RESGENGET | G0, GUE TE TELFPRONE HOMBER OF SYS TELEMONE ves Uno (as y eee er BOEASE GvE YOUR WORK TELEDIO}E WONGER 62 624 -459/ B AFTER YOU HAVE ANSWERED 1 THROUGH 11 ABOVE, SIGN OR MAKE YOUR MARK ON THE FOLLOWING OATH IN THE PRESENCE OF ‘THE REGISTRAR OR DEPUTY REGISTRAR. STATE OF MISSISSIPPI COUNTY OF 1 00 SOLEMNLY SWEAR (OR AFFIRM) THAT AMAT LEAST EIGHTEEN (18) YEARS OLO (OR | WILL BE BEFORE THE NEXT GENERAL ELECTION IN THIS ‘COUNTY), AND THAT | AM NOW IN'GOOD FAITH A RESIOENT OF THSS STATE AND OF ___ gecTion preonct INTIS COUNTY, ANO THAT | AM NOT DISQUALIFIED FROM VOTING BY REASON OF HAVING BEEN CONVICTED OF ANY CRIME LISTED IN QUESTION 10 (OF THE APPLICA 1 *V ANSWERED ALL QUESTIONS PROPOUNDED TO ME IN THE FOREGOING APPLICATION FOR REGISTRATION, ‘AND THAT FW {CONSTITUTION OF THE UNITED STATES AND OF THE STATE OF MISSISSIPPI, AND WILL BEAR TRUE FAITH ‘ND ALLEGIANCE. fe Goo. eu COAHOMA COU} P.O, BOX a9 ( CLARKSDALE, MS 38614 yy ee 2A BY [SOONTY PREGICT orice use oni) ORIGINAL: COUNTY REGISTRAR (CIRCUIT CLERK) — DUPLICATE: MUNICIPAL CLERK — TRIPLICATE: VOTER