MISSISSIPPI MAIL-IN VOTER REGISTRATION APPLICATION Agency Code:

• You can use this form to: register to vote in Mississippi or change your name and/or address.
• If you are registering for the first time in Mississippi and DO NOT have a Mississippi driver’s license or social security
number, you must send with this application a copy of a current and valid photo ID or a copy of a current utility bill, bank
statement, government check, paycheck or other government document that shows your name and address in this county.
• An application for voter registration must be postmarked or hand delivered to the Circuit Clerk’s Office located in the
county of your voting residence no later than 30 days before an election.
• You may not register to vote if you have been convicted in a Mississippi state court of any of the following crimes: voter
fraud, murder, rape, bribery, theft, arson, obtaining money or goods under false pretense, perjury, forgery, embezzlement,
bigamy, armed robbery, extortion, felony bad check, felony shoplifting, larceny, receiving stolen property, robbery, timber
larceny, unlawful taking of a motor vehicle, statutory rape, carjacking or larceny under lease or rental agreement.
• If you live in an area without house numbers or street names, please include a drawing of your location to enable us to
identify your appropriate voting precinct.
• Photo ID Required to Vote: You will be required to present an acceptable form of photo identification when you vote at
your polling place on Election Day or by absentee ballot in your Circuit Clerk’s Office, unless exempted by law. For more
information, go to www.MSVoterID.ms.gov or call (844) 678-6837.

Check One: Are you a citizen of the United States of America? Yes □ No □
□ New
Registration Will you be 18 years of age on or before Election Day? Yes □ No □
□ Change of NOTE: If you checked ‘No’ in response to either of these questions, DO NOT complete this form.
Information Would you like to serve as an Election Day poll worker? Yes □ No □
Last Name First Name Middle Name Maiden Name Suffix
Name

Physical Home Number and Street/Road/Dorm/Apt #

Address
(Where you City County State: Zip
live) MS
Mailing Street or Post Office Box
Address (If
different from City County State: Zip
above)
Month Day Year
Date of Birth
MS Driver’s License _______________________
Cell Work Number or Last 4 or
Phone # Digits of your Social
( ) ( ) ___ ___ ___ ___
Security Number
Email
Name Address
Previous
Registration City County State: Zip

VOTER DECLARATION- Read and Sign

I swear/affirm, under penalty of perjury, that:
• I am a U.S. citizen.
• I will be 18 years of age on or before the next general Election Day.
• I am a resident of Mississippi, this county and this city for at least 30 days.
• I have not been adjudicated as mentally incompetent.
• I have never been convicted of voter fraud or any other disenfranchising crime OR, if convicted, I have had my voting
rights restored as required by law.
• The address listed above is my legal place of residence.
WARNING: Giving false information to register to vote is a felony punishable by a fine of not more than $5,000 or
imprisonment for not more than 5 years, or both. Miss. Code Ann. § 23-15-17.
X __________________________________________________ Date: ______________________
Signature (or mark) of applicant

X ___________________________________________________ Date: _______________________

If applicant is unable to sign, the person who assisted the applicant

_______________________________________
Address

10/2021
 Postage
Required
Post Office will
FROM: not deliver
without proper
postage.

TO: County Circuit Clerk

ADAMS COUNTY COPIAH COUNTY ITAWAMBA COUNTY LINCOLN COUNTY PIKE COUNTY TISHOMINGO COUNTY
115 S. Wall Street P.O. Box 467 201 W. Main Street 301 S. First Street, Rm. 205 P.O. Drawer 31 1008 Battleground Drive,
Natchez,
MS 39120 Hazlehurst, MS 39083 Fulton,
MS 38843 Brookhaven, MS 39601
Magnolia, MS 39652 Rm. 2014
ALCORN COUNTY COVINGTON COUNTY JACKSON COUNTY LOWNDES COUNTY PONTOTOC COUNTY Iuka,
MS 38852
P.O. Box 430 P.O. Box 667 P.O. Box 998 P.O. Box 31 P.O. Box 428 TUNICA COUNTY
Corinth, MS 38835 Collins, MS 39428
Pascagoula, MS 39568 Columbus,
MS 39703 Pontotoc,
MS 38863 P.O. Box 184
AMITE COUNTY DESOTO COUNTY JASPER COUNTY MADISON COUNTY PRENTISS COUNTY Tunica, MS 38676
P.O. Box 312 2535 Hwy. 51 S., Rm. 201 P.O. Box 447 P.O. Box 1626 P.O. Box 727 UNION COUNTY
Liberty, MS 39645 Hernando, MS 38632
Bay Springs, MS 39422
Canton, MS 39046 Booneville, MS 38829
P.O. Box 298
ATTALA COUNTY FORREST COUNTY JEFFERSON COUNTY MARION COUNTY QUITMAN COUNTY New Albany, MS 38652

100 Courthouse, Ste. 1 P.O. Box 992 P.O. Box 305 250 Broad Street, Ste. 1 220 Chestnut Street, Ste. 4 WALTHALL COUNTY
Kosciusko,
MS 39090 Hattiesburg, MS 39403 Fayette,
MS 39069 Columbia,
MS 39429 Marks, MS 38646 200 Ball Avenue, Ste. C
BENTON COUNTY FRANKLIN COUNTY JEFFERSON DAVIS COUNTY MARSHALL COUNTY RANKIN COUNTY Tylertown,
MS 39667
P.O. Box 262 P.O. Box 267 P.O. Box 1090 P.O. Box 459 P.O. Box 1599 WARREN COUNTY
Ashland,
MS 38603 Meadville,
MS 39653 Prentiss, MS 39474 Holly
Springs, MS 38635 Brandon,
MS 39043 P.O. Box 351
BOLIVAR COUNTY GEORGE COUNTY JONES COUNTY MONROE COUNTY SCOTT COUNTY Vicksburg, MS 39181
P.O. Box 670 355 Cox Street, Ste. C P.O. Box 1336 P.O. Box 843 P.O. Box 371 WASHINGTON COUNTY
Cleveland, MS 38732 Lucedale,
MS 39452 Laurel,
MS 39441 Aberdeen, MS 39730 Forest,
MS 39074 P.O. Box 1276
CALHOUN COUNTY GREENE COUNTY KEMPER COUNTY MONTGOMERY COUNTY SHARKEY COUNTY Greenville,
MS 38702
P.O. Box 25 P.O. Box 310 P.O. Box 130 P.O. Box 765 P.O. Box 218 WAYNE COUNTY
Pittsboro, MS 38951
Leakesville, MS 39451 De Kalb, MS 39328
Winona, MS 38967
Rolling Fork, MS 39159 P.O. Box 428
CARROLL COUNTY GRENADA COUNTY LAFAYETTE COUNTY NESHOBA COUNTY SIMPSON COUNTY Waynesboro, MS 39367

P.O. Box 6 P.O. Box 1517 1 Courthouse Sq., Ste. 101 401 E. Beacon Street, Ste. 110 P.O. Box 307 WEBSTER COUNTY
Vaiden,
MS 39176 Grenada,
MS 38902 Oxford, MS 38655 Philadelphia,
MS 39350 Mendenhall,
MS 39114 P.O. Box 308
CHICKASAW COUNTY HANCOCK COUNTY LAMAR COUNTY NEWTON COUNTY SMITH COUNTY Walthall, MS 39771
1 Pinson Square, Rm. 2 152 Main Street, Ste. B P.O. Box 369 P.O. Box 447 P.O. Box 517 WILKINSON COUNTY
Houston, MS 38851 Bay
St. Louis, MS 39520 Purvis,
MS 39475 Decatur, MS 39327 Raleigh,
MS 39153 P.O. Box 327
CHOCTAW COUNTY HARRISON COUNTY LAUDERDALE COUNTY NOXUBEE COUNTY STONE COUNTY Woodville,
MS 39669
P.O. Box 34 P.O. Box 998 P.O. Box 1005 P.O. Box 431 323 E. Cavers Avenue WINSTON COUNTY
Ackerman,
MS 39735 Gulfport, MS 39502 Meridian,
MS 39302 Macon,
MS 39341 Wiggins, MS 39577 P.O. Drawer 785
CLAIBORNE COUNTY HINDS COUNTY LAWRENCE COUNTY OKTIBBEHA COUNTY SUNFLOWER COUNTY Louisville,
MS 39339
P.O. Box 549 P.O. Box 327 P.O. Box 1249 108 W. Main Street P.O. Box 880 YALOBUSHA COUNTY
Port Gibson, MS 39150
Jackson, MS 39205
Monticello, MS 39654 Starkville, MS 39759
Indianola, MS 38751
P.O. Box 1431
CLARKE COUNTY HOLMES COUNTY LEAKE COUNTY PANOLA COUNTY TALLAHATCHIE COUNTY Water Valley, MS 38965
P.O. Box 216 P.O. Box 718 P.O. Box 67 P.O. Box 346 P.O. Box 86 YAZOO COUNTY
Quitman, MS 39355 Lexington,
MS 39095 Carthage, MS 39051 Batesville, MS 38606 Charleston,
MS 38921 P.O. Box 108
CLAY COUNTY HUMPHREYS COUNTY LEE COUNTY PEARL RIVER COUNTY TATE COUNTY Yazoo City, MS 39194
P.O. Box 364 P.O. Box 696 P.O. Box 762 P.O. Box 530 201 Ward Street
West
Point, MS 39773 Belzoni, MS 39038 Tupelo,
MS 38802 Poplarville,
MS 39470 Senatobia, MS 38668
COAHOMA COUNTY ISSAQUENA COUNTY LEFLORE COUNTY PERRY COUNTY TIPPAH COUNTY
P.O. Drawer 849 P.O. Box 27 P.O. Box 1953 P.O. Box 198 102-A N. Main Street
Clarksdale, MS 38614 Mayersville,
MS 39113 Greenwood, MS 38935 New
Augusta, MS 39462 Ripley,
MS 38663