COUNTY OF

—REGISTRATION OF VOTERS

Last Name (Print)

First Name (Print) Middle Name

or Initial

Affiliation

Dist.

Prec.

Street Address

Post Office

Zip Code

Term of Residence

Precinct

County

State

Nativity (Where Born)

Date Naturalized

Day Month Year

Court of Naturalization

Date of Birth

Year

Month

Day

Age

Qualified

Yes__ No__

Why Disqualified

Disqualifying
Criminal Offense

Challenged

Sex

Date of Registration

Year

Month

Day

I do solemnly swear (or affirm) that the informa-
tion set forth hereon about my place of residence,
name, place of birth, criminal offenses, qualifications
as a voter, and my right to register and vote under
the laws of this State is true.

Signature of Applicant

Cannot Sign

Mark

If applicant
cannot sign

Height_____

Eye Color.

Distinguishing Marks:

Signature of Registrar

Signature of Registrar

Voting Record

(When Elector votes, record letter "V": in proper Space)

(Registrar—Do Not Write Below)

Year

66|67|68|69|70

71

72|73|74

75|76|77|78|79|80|81|82|83|84|85|86|87|88|89|90|91|92|93|94|95|96|97|98

99|00

Special

Primary

General