APPLICATION FOR REGISTRATION, QUESTIONNAIRE AND OATHS

PART I

CI'b1l 1.1 to be tilled In by a member of the Board of Rei:!~tr&rs or a duly authorized clerk of the board. U applicant Is a married woman, abe must &tate Jl,ven name by which abe 1.1 known, malden surname, and man1ed surn&me, which ahall be recorded aa her full oe.me.)

Full Name:--;-~-------------­Lut

Date of Birth: _______________ _

Residence Address: ___________ _

First

_sex ___________ _ Mlddle

• Race _____________ __

Mailint Address:_------- .,. -------------~----------------------------

Voting Place: Prccinet _________ _____ Ward_ ________ _ District ____ ___ _

Length of Relidence: In sta...._ _______ ______ County

Precinct, ward or di.stri.,.._ _ _______ _ _ -------------Are you a member of the Armed Forces? ______ _

Are you the wife of a member of the Armed Forces? ____________________________ _

Are you a eollege student? ____ _ __ If so, where ________________________________ _

Have you ever been registered to vote. in any other state or in any other eounty in Alabama?.~-- If so, when and in

what state and eounty and, if in Alabama, at what place did you vote in such county? _______________ _

Highest grade, 1 to 12, eompleted'---------Where --- - --- ---- -------------------

Years college eompleteu... ______ _ _ __Where

PART II

(To be tilled In by the applieant In the praence of the Board of Rertatrars without assistance.)

MONTGOMEh). I, - - - ---------------------• do hereby apply to the Board of Registrars of

County, State of Alabama, to register as an elector under the Constitution and laws of the State of Alabama and do here-

with submit my answers to the interrogatories propounded to me by the board.

to:;tmature of Applicant)

1. Are you a citizen of the UDited States? ----------------------------------------2. Where were you born? ____________ ___________________________ _____ _

3. If you are a naturalized citizen, give number appearing on your naturalization papers and date of issuance ____ _

4. Have you ever been married? ____ ..Jicrf so, give the name, residence and place of birth of your husband or wife ___ _

Azeyou divo~?---------------~--------------------------------------

5. List the places you have lived the past five years, giving town or county and state~------------------

6. Have you ever been lmown by any name other than L" one appearing on this application? ____ If so, state what name

7. Are you employed7 ___ ~Iuf so, state by whom. (If you are self-employed, state this.) ________ , ___ __ _

8. Give the address of your present place of employment..

9. If, m the past five years, you have been employed by an employer other than your present employer, give name of all em-

players and cities and states in which you worked ___ ·------------------------- -

10. Has your name ever been stricken for any reason from any list of persons registered to vote? ___ ._If so, where, when,

and why? ______________________________ _______ _____ _

11. Have you previously applied for and been denied reglStration as a voter? ____ If so, when and where? ___ ___ _

12. Have you ever served in the Armed Forces? _ __::.__ ___ , ____ _ulf so, give dates, branch of service, and serial number

13. Have yoou ever been diahonorably discharged from military service? _____________________ _

14. Have you ever been declared leeally insane?. ____ __.f so, give details ____________ _

15. Give names and addresses of two persons who know you and can verify the statements made above by you relative to

your residence in thia ltate, county and precinct, ward or distric._ ______________________ _

16. Have you ever seen a copy of this registration application form before receiving this copy today?. ___ .ulf so, when and

where? -------- - -------- ------------------------------ -

17. Have you ever been convicted of any offense or paid any fine for violation of the law? (Yes or No) If so, give the following information concerning each fine or conviction; charge, in what court tried, fine imposed, sentence, and, if paroled, state when, and if pardoned, state when. (If fine is for traffic violation only, you need write below only the

words "trafiic violation only.") ______ _

(Remainder of th.la form 1.1 to be 1llled out only as directed by an Individual member of the Board of Registrars.)

PART ni Part m of thla queatl.onnalre shall co...ut of one of the fonns whic h are Insert Part Ill as herein below set ou t. The insert shall be taaten.ed

:~~~~':,.'1;"~\~"·to ~"J~~f:t ~u;~~~~ ~eg.,sh~~n~1tu~:'"~1dA~~=~s t~m~".ie~.·~~ti:P~.;~~;;;t b~u~onsT3i~eda':lii::! ~~!~ pleted this application. nor llhall the name of any appllcant be entered upon the list of regj.stered v oters of any county until after auch Inserted Part m of the queltlonnalre hu been satisfactorily completed and signed by the applicant.

STATE OF ALABAMA

____ ___::..:__:c__ _ _____ COUNTY

Before me.---

PLEASE INSERT PART III HERE

PART IV

OATHS

a reiistrar in and for said county and state, personally appear=----------· --------­

an applicant for registration as an elector, who being first duly sworn deposes and says:

"I do solemnly swear (or affirm) that the foregoing answers to the interrogatories are true and correct to the belt of my

knowledge, information and belief. I do further personally swear (or affinn) that I will support and defend the Constitution of

the United States and the Constitution of the State of Alabama; that I do not believe in nor am I affiliated with any II'OUP or

party which advocated or advocates the overthrow of the United States or the State of Alabama by unlawful IJleaDL I do

further solemnly swear (or affirm) that in the matter of this application for registration I have spoken the truth. the whole

truth and nothing but the truth, so help me God."

(Signature of Appllcant)

Sworn to and subscribed before me this the _ ____ day of ... ----- - - ------------ ·-·-• 19 __ ,

(Signatur .. of Board Member)

EXPLANATION AND REMARKS

(Board members interviewing applicants may place here any special explanations, such as of residence status, or othet'

remarks for purposes of clarification. If person is blind or is otherwise physically handicapped to such an extent that be can­

not fill out this application form, the circumstances are to be r ecorded here, along with an explanation of the method UMld to

determine if the person is, in fact, literate and can spell words and recognize those spelled to him, or can read larp block

letters and words in the case of persons with sight handicaps·---------------- ----------

.... .. PARTV

ACTION OF THE BOARD

STATE OF ALABAMA

_ ___________ coUNTY

The rJplicant, , appeared before the board of r egistrars for said state aDd county in a regular session and executed the foregoing application in the manner prescribed by law. The Board, having further examined said applicant under oath, touching his qualifications under Section 181, Constitution of Alabama, as amended, and having fully considered the foregoing application for registration, questionnaire and oaths, adjudges said applicant entitled to

be registered and he was duly registered this the_~---.... day of- -------··- ----·-··-······-· ... __, 19 __ _

Signed: Chairman

Member

(NOTE: The act of actually determining an appllcant entlUed to be registered Is judicial. A majortty of the Board mu.t CODCIIJ'. A m.ajortty must be present. The power cannot be delegated. Each member must v ote on each application. Not unW tiWI 1a doDe ma:r a c:ertlflcate be Issued the appllcant.)

The Applicant.----------------------- ·-----··• due to failure to meet the requirements of state law for reP..

tration as an elector, is hereby rejected on this the ______ day oL--- -··-·-··- ----··-······- ___ ··-·--·-·-··-·• 19 ___ _

Signed: .. _ __ ___ _ Chairman

Member

Mernber

PART VI

EXAMINATION OF SUPPORTING WITNESS

(The witness shall be placed under oath to tell the truth, the person adminlstertng the oath belnl a Board member or otber ~ . authorized to administer oaths and acting under the direction of the Board.)

Name of Witness. --------······-----·--- -··-·······-·····--·--··--- ----

Place of Voting. _____ _

"I have known the applicant___ __ --------------·-··--·for ______ years an~ ... ____ __.m .. ontha

and I have pel'S'onal knowledge that his place of restaence· "1s------·-··-· --------·----------- --- - -

and that he has resided in the State of Alahama ;;ot least one year and in_ ________ County for at least six montha."

Signature of Wltnesa

Sworn to and subscribed before me this the ________ day of _________ _ 19 _ _

····---··----·-- --------- - ··-·---- --------------··-·-(Person Administering Oath)

Date.·-···------------·-··-----·-·-----