Missouri Code of State Regulations
Title 15 - ELECTED OFFICIALS
Division 30 - Secretary of State
Chapter 4 - Postcard Voter Application and Forms
Section 15 CSR 30-4.010 - Postcard Voter Application and Forms

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;

3. New Registration ___ Address Change ___ Name Change ___ Political Party Affiliation;

4. (Full Legal Name) Last Name ______First Name______Middle Name ______Suffix Jr. __ Sr. __ II __ III __ IV __ Male ___ Female ___;

5. Address where you live (House No., Street, Apt. No. or Rural Route and Box - No PO Box) __________City ______County _____Zip Code _____;

6. Address where you get your mail (Required if different from #5 above) __________City ______ County ______Zip Code _____;

7. Driver's License Number (If you do not have a driver's license, please leave blank);

8. Last 4 digits of Social Security Number (If you do not have a Social Security Number, 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 - Name __________ Address __________City ________State ____County ______

(If currently registered in another state or county, please complete this box);

14. I hereby certify that I am a citizen of the United States and a resident of the 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 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 election offense and may be punished by imprisonment of not more than five (5) years or by a fine of between two thousand five hundred dollars ($2,500) and ten thousand dollars ($10,000) or both such imprisonment and fine.

Date_________________________

Signature________________________;

15. Political Party Affiliation (optional) ___ Republican ___ Democratic ___ Libertarian ___ Unaffiliated _____ Other.