Public Service Request Voter Registration (Historic)
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Public Service Request Voter Registration (Historic)
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PSR
Request for Voter Registration Data
Name (Print): ________________________________________________________________________
Address: ____________________________________________________________________________
City, State & Zip: _____________________________________________________________________
Telephone Number: __________________________________________________________________
Please include detailed description of your request for voter registration data and what it is to be
used for (please indicate format you are requesting from list below): ___________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Circle Format Requested Cost Labor Fee
Letter = .10 per page
$ _______.____/hour
Copies Legal = .15 per page
C.D. $10.00 per C.D. - Includes Labor -
Voter Address Labels .35 per sheet of labels $ _______.____/hour
Note: First 5 minutes of labor is free. Total Time of Labor: ______:______
Total Cost of Items: $ _______.____ + Total Cost of Labor: $ _______.____ = Total Cost: $ ______.____
NOTICE OF APPROPRIATE USE
**MUST READ & SIGN BEFORE REQUEST IS VALID**
Section 115.158 RSMo prohibits commercial use of Centralized Voter Registration System Information.
The statute states: “…Any information contained in any state or local voter registration system, limited to
the master voter registration list or any other list generated from the information, subject to chapter 610,
RSMo, shall not be used for commercial purposes; provided, however, that the information may be used for
elections, for candidates, or for ballot measures, furnished at a reasonable fee. Violation of this section shall
be a class B misdemeanor.” "Commercial purposes" means the use of a public record for the purpose of sale or resale or for the purpose
of producing a document containing all or part of the copy, printout, or photograph for sale or the obtaining of names and addresses from public
records for the purpose of solicitation or the sale of names and addresses to another for the purpose of solicitation or for any purpose in which the
purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of the public record.
By your signature below, you represent that you will not use, nor will you knowingly or negligently
permit others to use this information for commercial purposes.
_____________________________________ _______________________________
Signature Date
Request taken by: ______________________________________________________ Deputy Clerk.
Date Paid:_____________________________________
Amount Paid: __________________________________
How Paid: Check # _________ Cash: _________
Payment Received By: ___________________________ (Deposit in Election Fund Account)
Revised by: J. Yust on 11/10/2009
Public Service Request Voter Registration (Historic)
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