Missouri Voter Registration Application Please enable JavaScript in your browser to complete this form.1. ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA? *YESNO2. WILL YOU BE 18 YEARS OF AGE ON OR BEFORE ELECTION DAY? *YESNO3. TYPE OF APPLICATION *NEW REGISTRATIONADDRESS CHANGENAME CHANGE4. NAME *FIRST NAME *MIDDLE NAME *SUFFIX *SEX *MALEFEMALE5. HOME ADDRESS *CITY *COUNTY *ZIP *6. MAILING ADDRESS *CITY *MO *ZIP *7. DRIVER'S LICENSE NUMBER8. LAST 4 DIGITS OF SOCIAL SECURITY NUMBER9. DATE OF BIRTH *10. PLACE OF BIRTH11. DAYTIME PHONE NUMBER12. EMAIL ADDRESS13. LAST VOTER REGISTRATION INFORMATIONADDRESSCITYSTATECOUNTYIF CURRENLTY REGISTERED IN ANOTHER STATE, PLEASE COMPLETE ALL OF #13 ABOVE14. I hereby certify that I am a citizen of the United States and a resident of thet state 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 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 perjury that all statements made on this card are true to the best of my knowledge and belief. I understand that if I register to vote knowing that I am not legally entitled to register, I am committing a class one elcection offense and may be punished by imprisonment of not more than five years or by a fine of between two thousand five hundred dollars and ten thousand dollars or by both such imprisonment and fine. *SIGNATURE *15. RURAL VOTERSN, S, E, OR WLANDMARKSECTIONNEIGHBORSELECTION JUDGECHECK HERE IF YOU ARE INTERESTED IN WORKING AS AN ELECTION JUDGESubmit
