Fill and Sign the Lawn Care Invoice Template Form

MISSISSIPPI VOTER REGISTRATION APPLICATION IMPORTANT! • If you are not registered to vote where you now live, you can use this form to register to vote or report that your name or address has changed. • If you have questions call your county Circuit Clerk or call the Secretary of State at 1-800-829-6786. • Complete all sections of this form, then mail or hand deliver it to your county Circuit Clerk AT LEAST 30 days before the election in which you want to vote. • If you are qualified and the information on your form is complete, you will be mailed a voter card that tells you where to vote. Section I. APPLICATION TO REGISTER TO VOTE Please select one of the following: New Registration □ 1) Are you a citizen of the United States of America? Change of Information □ Yes □ 2) Will you be 18 years of age on or before Election Day? Yes □ 3) Would you like to serve as an Election Day Poll Worker? CIRCLE Mr. Mrs. Miss Ms. Last Name: No □ No □ Yes □ NOTE: If you checked “No” in response to questions 1 or 2, do not complete this form. No □ First Name: Physical Home Address (Number & Street/Road/Dorm/Apt. or Lot #): Middle/Maiden Name: City: Mailing Address (if different from above, include zip code): County: Suffix: (JR, II) State: MS Zip: Date of Birth: Mississippi Driver’s License Number (If you do not have a driver’s license, then list the last 4 digits of your Social Security Number): *** ***Identification Requirement: If you do not have a driver’s license or social security number, and this form is submitted by mail, and you have never registered to vote in the county you are now registering in, you must send, with this application, either a) a copy of current and valid photo identification, or b) a copy of a current utility bill, bank statement, government check, paycheck, or other government document that shows the name and address of the voter. If you do not provide the information requested above, you may be required to provide to election officials either (a) or (b) above the first time you vote after January 1, 2004 at a voting place or by absentee ballot. Section II. IF YOU WERE PREVIOUSLY REGISTERED UNDER A DIFFERENT NAME OR ADDRESS, LIST THAT NAME OR ADDRESS CIRCLE Mr. Mrs. Miss Ms. Last Name: First Name: Middle/Maiden Name: Suffix: (JR, II) Previous Address (Number & Street/Road/Dorm/Apt. or Lot #): Previous City: Previous County: Previous State: Previous Zip: Section III. VOTER DECLARATION- Read and Sign I swear/affirm that: I am a U.S. citizen. I will have lived in this state and county for at least 30 days before voting, and if a resident of a municipality, I will have lived in the municipality for at least 30 days before voting. I have never been convicted of murder, arson, armed robbery, bigamy, bribery, embezzlement, extortion, felony bad check, felony shoplifting, forgery, larceny, obtaining money or goods under false pretense, perjury, rape, receiving stolen property, robbery, theft, timber larceny, unlawful taking of a motor vehicle, statutory rape, or carjacking, or I have had my rights restored as required by law. I have not been declared mentally incompetent by a court. Furthermore, I certify that I am at least eighteen (18) years old (or I will be before the next general election), the information given by me is true and correct and that I have truly answered all questions on this 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. X ______________________________________________________ Date: ______________________ Signature (or mark) of applicant X ______________________________________________________ If applicant is unable to sign, the person who assisted the applicant must sign above _____________________________________________ Daytime phone number(s) where applicant can be reached WARNING: False registration is a felony. The penalty for conviction of false registration is imprisonment for not more than five (5) years or a fine of not more than five thousand dollars ($5000), or both. 07/2004 Date: _______________________