FOR US. CITIZENS ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  
 

 

 

 

  
 
  
   
  

FOR CLERKS USE ONLY
'3 new address DEW El PRECINCT PRECINCT OTHER
Check one: registration change change change CODE NAME CODE
Social Security No. Date of Birth County
170 eaumon-i he

Last Name First Name Middle Name Suffix [circle one
. . II IV
I mega-v 
Address Where You Live (80 not give P.O. address) ?gene City Zip Code
1 1111 FIFBIJMFIMT F?hiTFil I 133331;? .e 3" a- w. :2
Address Where You GEIYouriIi-eil (Ii dilf'Erent Irorn 1 - 5 .5. ii City Zl ?Cc dis.?
L. .Ugu-?u r? i .
out. . .1
1 a} 
Work Phone 53:9, his statement even though you know it Is untrue. you
Female E: be convi mdf?lr?bd up to $500 and/or jailed up to 12 months

Home Phone Declaration?? read end below

gm or affirm . - 

5, a a U. S. citiz?

Hill In was listed above
Party one before the next general elacllon

l: trig be a reel Poi. the-'cuunty for at least twenty- eight days prior to the

mmocm?c Party PLEASE - . "?ed iron or if I have been convicted of a felony my civil
If you select - restored by executive pardon
your party gee ?mentally incompetent? in a court of law

are eligible to vote
nonpanlsen offices In em on

Republican Party

7: ..


lie right to vote anywhere outside Kentucky

I

 

primary electlon. You may
vote for any candidate in all

D. Other (write name below)
general or special electlons.

 

z:

Signature a 9312' a Date 2.25%

WITN ESSED BY:

 

Note: You me change your political party affiliation at any
time on or be ore December 31?to remain eligible to vote
In the following primary election. Only persons timely
registered she I eve the right to vote.



WITN ESSED BY:



7 

 

see 01 (6101)

 

 

 

TWO WITNESSES REQUIRED IF i3 USED