FOR US. CITIZENS ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR CLEHKS USE ONLY
new address name mar

Check one: registration change 53339.; change mg a (23ng
Son-Eel Seounty No. IDate oi Birth County A 1L

03-03-73 FAYETTE ?30 
feat Name First Name Middle Name Suiflu [circle one]

I NDEMAN I EHDRE 

Address Where You Live (do not give HO. address] Ant. ll City Zip Code

   
 
 

  

11o1 CENTRE LN 232 oxmo on on:-
Where li?ou Get Hour Mali (it dltlerenl from above] City Zip Code


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- - stateroom own though you known is untrue. you
oi up to $500 endl'ar jailed up to 1'2 months.

  

 

Work Phone I 59, 3?3" 1' .
Female 

 

 

Home Phone . sign below

 

 

 
 
 
    
    
     
  
 
  

I ?-955 "sled above
- . logo on or before the next general election

Party Registration?chock one box 
- .. only for at least twenty-eight days prior to the

     

    
   
   
 

PLEASE - 3 - an or If I have been convicted of a felony my civil
El Democratlc Party If you select . 2 restored by executive pardon
your party -- af?lg", ?mentally Incompetent? in a court of law
Republican Party are eligible to vote . ?14- .- right to vote anywhere outside Kentucky

'4 "5 ,5 ..
nonpartisan offices In 5:ka
primary election. You may 
Other (Wm mm below) vote for any candidate In ell 

general or special elections. Sig nature

WITNESSED BY: 

 

Date if

 

 

 

Note: You me change your political party affiliation at any
time on or be re December 3i'to remain eligible to vote WITNESSED BY:

In the toliowln grime election. Only persons timely 6 3 2003
registered aha I an a right to vote.
see 01 (em)

 

 

 

 

TWO WITNESSES REQUIRED IF IS USED