Missouri Voter Regstration Application

MISSOURI VOTER REGISTRATION APPLICATION
Use this application to: Box 5 -- Home Address
1. Register to vote in any election in Missouri. (New Registration) List your home address. DO NOT put your mailing address if it differs from your
2. Register to vote when you move from one jurisdiction (St. Louis City, Kansas home address.
City, or any county) to another jurisdiction (St. Louis City, Kansas City, or any
county) within Missouri. (New Registration) Box 6 -- Mailing Address
3. Change the address on a current voter registration when you move within a If you get your mail at an address other than your home address in Box 5, put that
jurisdiction. (Address Change) address here in this box.
4. Change the name on a current voter registration. (Name Change)
Box 7 -- Driver’s License Number
Other information: Required for registration unless you do not have a Driver’s License. (§115.158,
1. You must be 18 years of age by the day of a particular election to be eligible to RSMo.) If you do not have a Driver’s License, leave blank.
vote in that election.
2. If mailed, this form must be postmarked by the 4th Wednesday preceding an Box 8 -- Last Four Digits of Social Security Number
election to be eligible to vote in that election. If delivered in person, it must be Required for registration unless you do not have a Social Security Number. (§115.155,
received in the office by the 4th Wednesday preceding an election. (See reverse RSMo, §115.158, RSMo.) If you do not have a Social Security Number, leave blank.
for election calendar.) Box 9 -- Date of Birth
3. Submitting this application to an individual other than the election authority Place your date of birth in this box (Month, Day, Year). DO NOT USE TODAY’S DATE!
does not insure timely voter registration.
4. After the election authority receives your voter registration application, you will Box 10 -- Place of Birth (Optional)
be sent confirmation within 7 business days. If you do not receive confirmation, List your place of birth (city/county/state).
contact the election authority.
5. If you wish to serve as an election judge on election day please contact your Box 11 -- Daytime Phone Number (Optional)
local election authority and mark the box at the bottom of this form. Please list a number at which the election authority may contact you for clarification
6. Optional—If registering by mail for the first time, please submit a copy of one of of information.
the following forms of identification: current or valid photo ID, current utility bill,
bank statement, government check, paycheck or other government document Box 12 -- Email Address (Optional)
that shows your name and address, birth certificate, Native American tribal Please list an email address at which the election authority may contact you for
document or other proof of United States citizenship. (You will be required to clarification of information. This email address may only be used for election related
present government issued photo identification when you vote or vote provi- communication from the election authority.
sional.)
Box 13 -- Last Voter Registration Information
Completing this form (All information is required unless indicated as optional): If you are currently registered, please list the name and address of your last regis-
Boxes 1 and 2 -- Citizen and Age Requirements tration including county and state.
Federal Law requires voter registration applicants to answer these two questions.
Box 14 -- Signature
Box 3 -- Type of Application Review the information. If you meet the requirements and all is correct, sign your
Check appropriate box if this is a new registration or if you are changing a name or full name or make your mark and print today’s date.
address on your current voter registration.
Box 15 -- Political Party Affiliation
Box 4 -- Name Check the box next to one of the established political parties you wish to affiliate
Put in this box your full name (Last, First, Middle). DO NOT use nicknames or initials. with or check unaffiliated. You will be designated unaffiliated if there is no affiliation
For name changes, Box 13 should contain your old name. checked on the form.
YOUR APPLICATION WILL BE CONFIRMED BY MAIL WITHIN SEVEN (7) BUSINESS DAYS OF ITS RECEIPT BY THE
ELECTION AUTHORITY. PLEASE CONTACT THE ELECTION AUTHORITY IF YOU DO NOT RECEIVE NOTIFICATION.
(DETACH HERE - KEEP TOP PORTION FOR YOUR RECORDS) This card is not proof of registration.

MISSOURI VOTER REGISTRATION APPLICATION
USE PEN - PLEASE PRINT CLEARLY PC
1 ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA? YES NO 2 WILL YOU BE 18 YEARS OF AGE ON OR BEFORE ELECTION DAY? YES NO

If you checked no in response to either of the above questions, do not complete this form.
3 NEW REGISTRATION ADDRESS CHANGE NAME CHANGE FOR OFFICE USE ONLY REGISTRATION NO.
4 LAST NAME FIRST NAME MIDDLE NAME SUFFIX
MALE FEMALE

5 ADDRESS WHERE YOU LIVE (HOUSE NO., STREET, APT. NO. OR RURAL ROUTE AND CITY COUNTY ZIP CODE
BOX - NO PO BOXES)

6 ADDRESS WHERE YOU GET YOUR MAIL (REQUIRED IF DIFFERENT FROM #5 ABOVE) CITY STATE ZIP CODE

7 DRIVER’S LICENSE NUMBER 8 LAST 4 DIGITS OF SOCIAL SECURITY NUMBER*
IF YOU DO NOT HAVE A DRIVER’S LICENSE, IF YOU DO NOT HAVE A SOCIAL SECURITY NUMBER, PLEASE LEAVE BLANK.
PLEASE LEAVE BLANK.

9 DATE OF BIRTH (MM/DD/YYYY) 10 PLACE OF BIRTH (OPTIONAL) 11 DAYTIME PHONE NO. (OPTIONAL) 12 EMAIL ADDRESS (OPTIONAL)

13 NAME AND ADDRESS ON LAST VOTER REGISTRATION 14 I hereby certify that I am a citizen of the United States and a resident of the state
NAME
of Missouri. I am at least seventeen and one half years of age. I have not been
adjudged incapacitated by any court of law. If I have been convicted of a felony or a
ADDRESS misdemeanor connected with the right of suffrage, I have had the voting disabilities
resulting from such conviction removed pursuant to law. I swear under penalty of
CITY STATE
perjury that all statements made on this card are true to the best of my knowledge
COUNTY and belief. I understand that if I register to vote knowing that I am not legally entitled
If currently registered in another state or county please complete this box. to register, I am committing a class one election offense and may be punished by
imprisonment of not more than five years or by a fine of between two thousand five
15 POLITICAL PARTY AFFILIATION (OPTIONAL) hundred dollars and ten thousand dollars or by both such imprisonment and fine.
REPUBLICAN DEMOCRATIC
LIBERTARIAN UNAFFILIATED
Date Signature

Check here if you are interested in working as an Election Judge Warning: Conviction for making a false statement may result in imprisonment for up to five years and/or a fine up to $10,000.
MO 231-0169 (REVISED 11/2022) *Required for registration pursuant to §115.155 RSMo and §115.158 RSMo.