Appendix A to Part 801

This appendix sets out the dates, times, and places designated by the OPM for filing an application in each political subdivision, and sets out the forms of application prescribed by the OPM.

Dates, Times, and Places for Filing

Offices at which applications may be filed will be open in each State in the county or parish and at the place set forth in this appendix beginning on the date specified and continuing thereafter until a closing date is given. Each office will be open Monday through Saturday (except on a legal holiday) between the hours of 8:30 a.m. and 4:30 p.m., except that the OPM may change the hours and days on which any office will be open for filing applications by posting advance notice of the change at the place set forth in this appendix.

Alabama County; Place for filing; Beginning date

Autauga; (1) Prattville—U.S. Post Office; November 8, 1965; (2) Marbury—building adjacent to U.S. Post Office, intersection of Main Street and State Highway 143; February 26, 1966.

Barbour; Holiday Inn, Room 101, Barbour St. at Riverside Drive, Eufaula, Alabama, 36027, [phone].

Bullock; Union Springs—U.S. Post Office, 108 E. Hardaway Street; November 7, 1978.

Chambers; Lafayette—Examiners Office, Room 218, FHA Office, County Building, 18 Alabama Avenue E.; July 30, 1984.1/8

Choctaw; Butler—Post Office; May 31, 1966.

Conecuh; Evergreen—Holiday Inn, Room 108, Interstate 68 and Highway 83; September 2, 1980.

Dallas; (1) Selma—Federal Building; August 10, 1965; (2) Orrville—U.S. Post Office, State Highway 22; February 26, 1966.

Elmore; (1) Wetumpka—U.S. Post Office; November 8, 1965; (2) Eclectic—trailer at U.S. Post Office; February 26, 1966; (3) Elmore—trailer at U.S. Post Office; February 26, 1966.

Greene; (1) Eutaw—U.S. Post Office; November 8, 1965; (2) Boligee—trailer at U.S. Post Office; March 8, 1966.

Grenada; Grenada—Post Office Building; July 22, 1966.

Hale; (1) Greensboro—Post Office Building; August 10, 1965; (2) Moundville—Tidmore Building; February 26, 1966.

Jefferson; (1) Bessemer—Post Office Building, North 19th Street, January 24, 1966; (2) Birmingham—Post Office and Courthouse Building, 18th at 5th Avenue, North; January 24, 1966; (3) Fairfield—4412 Gary Avenue; January 24, 1966; (4) North Birmingham—Post Office Building; 2003 41st Avenue (Sayreton), Birmingham; February 14, 1966; (5) Powderly—Library Building, Birmingham Baptist College, 630 Ishkooda Road, Birmingham; February 14, 1966; (6) Wylam—trailer at Post Office, 4221 7th Avenue (Wylam), Birmingham; February 21, 1966; (7) Irondale—7949-A Crestwood Boulevard; February 26, 1966; (8) Homewood—1820 28th Avenue; February 26, 1966; (9) Tarant—1322 Main Street; March 18, 1966.

Lowndes; (1) Fort Deposit—Post Office Building; August 10, 1965; (2) Hayneville—trailer at U.S. Post Office; January 3, 1966.

Madison; (1) Canton—285 Peace Street; August 10, 1965; (2) Flora—Segrist Building opposite post office; July 20, 1966.

Marengo; (1) Demopolis—Post Office Building; August 10, 1965; (2) Putnam—trailer adjacent to Post Office; State Highway 69; March 18, 1966.

Monroe; Room 112, Monroe Motor Court South, Highway 21, Monroeville, Alabama. August 31, 1984.

Montgomery; (1) Montgomery—Post Office and Courthouse Building, corner of Church, Lee, and Moulton Streets, Rooms 332, 334, 336; October 6, 1965, to November 6, 1969; (2) Montgomery—Aronov Building, 474 South Court Street, Room 132; November 7, 1969; (3) Mount Meigs—trailer at U.S. Post Office, intersection of U.S. Highway 80 and Pike Road; February 26, 1966.

Perry; (1) Marion—Post Office Building, Room 3; August 20, 1965; (2) Uniontown—trailer at corner of West and Front Streets; March 5, 1966.

Pickens; Carrollton—U.S. Post Office, Room 200, Courthouse Square, Highway 86; September 5, 1978.

Russell; Phoenix City—U.S. Post Office, 1310 Ninth Avenue; September 26, 1978.

Sumter; Livingston—Post Office; May 3, 1966.

Wilcox; (1) Camden—Federal Building, Room 202-204; August 20, 1965; (2) Alberta—trailer at intersection of State Highway 5 and County Highway 29; March 5, 1966; (3) Pine Apple—trailer at U.S. Post Office, County Highway 59; March 5, 1966.

Arizona County; Place for filing; Beginning date.

Apache; Window Rock Motor Inn, P.O. Box 1687, Window Rock, Arizona; October 31, 1986.

Navajo; Holiday Inn, P.O. Box 307, Kayenta, Arizona; October 31, 1986.

Yuma; U.S. Border Station, Highway 95, International Borderline, San Luis, Arizona, 85349; [phone]; February 26, 1991.

California

County; Place for filing; Beginning date

Alameda; Oakland-U.S. Attorneys Office, Oakland Branch, 1301 Clay Street, Suite 3405, Oakland, California, 94612; [phone] and [phone]; March 23, 1996.

Georgia County; Place for filing; Beginning date

Baker; Newton—U.S. Post Office Building; Nov. 5, 1968.

Baldwin; ASCS, Post Office Building, 110 Handcock Street, Room 206, Milledgeville, Georgia; Sept. 21, 1984.

Brooks; Georgian Motel, room 8, 803 East Screven Street, Quitman, GA 31643; [phone] or 263-9307, July 17, 1990.

Bulloch; Statesboro—Federal Building, Conference Room 208, 52 North Main Street; August 5, 1980.

Burke; Waynesboro-U.S. Post Office, 721 Liberty Street, Room 204; November 2, 1982.

Butts; (1) Jackson—Daughty Foundation, 221 College Street; September 4, 1982; (2) Flovilla—Flovilla Community Center, Collier Street; September 4, 1982; (3) Jenkinsburg—Cleveland BBQ Restaurant Building, Corner of Highway 42 and High Falls Road; September 4, 1982.

Calhoun; Morgan—Soil Conservation Service, Main Street, P.O. Box 113; August 5, 1980.

Chattahoochee; U.S. Post Office Lumpkin Highway, Cusseta, Georgia; Sept. 21, 1984.

Early; Blakely—Qual Motel, Room 26, U.S. 27 South; August 5, 1980.

Hancock; Sparta—Post Office Building, Broad Street; November 8, 1966.

Jefferson; Post Office Building Room 4, 131 W. Broad Street, Louisville, Georgia; Sept. 21, 1984.

Johnson; Wrightsville—U.S. Post Office, Basement Office 1, 151 South Marcus; August 5, 1980.

Lee; (1) Leesburg—Farmers Exchange Building, Second Floor; April 3, 1967, through April 30, 1969; (2) Leesburg—U.S. Post Office, intersection of State Highway 32 and U.S. Highway 19; May 1, 1969.

McIntosh; Best Western, Swiss Inn, room 115, Highway 251 and Interstate 95, Darien, Georgia 31304; [phone] or 4421; July 21, 1992.

Meriweather; Greenville—U.S. Department of Agriculture, Agricultural Stabilization Conservation Service Office, Williams Street; August 10, 1976.

Mitchell; Camilla—FHA District Office Conference Room, Building 10A, Broad Street; August 5, 1980.

Peach; Fort Valley—U.S. Post Office Building; 300 West Church Street; November 7, 1972.

Pike; ASCS, Pike County Agriculture Building, Gwyn Street, Zebulon, Georgia; Sept. 21, 1984.

Randolph, Travelers Mini Lodge, Room 2, 949 Blakely Street, Cuthbert, Georgia, 31740; [phone] or 5807; August 11, 1992.

Screven; Sylvania—Post Office Building, Main and East Telephone Streets; April 3, 1967.

Stewart; Lumpkin—U.S. Department of Agriculture, Agricultural Stabilization Conservation Service Office, Meeting Room, Court House, Second Floor; August 10, 1976.

Sumter; Americus—Federal Building and Court House, Basement Conference Room 128, East Forsyth Street; August 5, 1980.

Talbot—Buice Motel, Room 2, Washington St., Talbotton, Georgia 31827, August 9, 1988.

Taliaferro; Crawfordville—Post Office; November 5, 1968.

Telfair; McRae—Postmasters Office, U.S. Post Office, 211 South Second Avenue; August 5, 1980.

Terrell; Dawson—Post Office Building, Stonewall and Lee Streets; April 3, 1967.

Tift; Tifton—FHA, Conference Room 306, Tifton County Administrative Building, 225 Tift Avenue; August 5, 1980.

Twiggs; Jeffersonville—County Office Building; State Highway 96; September 3, 1974.

Worth; ASCS, Worth County ASCS Building, 501 N. Henderson, Sylvester, Georgia; Sept. 21, 1984.

Louisiana Parish; Place for filing; Beginning date

Bossier; (1) Benton—trailer at Post Office; April 3, 1967; (2) Bossier City—Lodge Hall, 1708 Scott Street; April 5, 1967 through March 17, 1969; (3) Bossier City—Post Office, 150 Benton Road, March 18, 1969.

Caddo; (1) Shreveport—Post Office and Courthouse Building, 424 Texas Street; April 3, 1967; (2) Shreveport—Terry Building, 2643 Cooper Road; April 3, 1967; (3) Shreveport; Hollywood Baptist Church; 5305 Roberts Street; April 3, 1967.

De Soto; Mansfield—trailer, at Post Office; April 3, 1967.

East Carroll; (1) Lake Providence—Post Office Building; August 10, 1965; (2) Sondheimer—trailer at Post Office Building; February 14, 1966; (3) Lake Providence—ASCS Office, 205 North Hood; October 19, 1979.

East Feliciana; (1) Clinton—Kline Building, St. Helena Street; August 10, 1965, to February 8, 1966; (2) Clinton—Trailer at U.S. Post Office; February 19, 1966; (3) Jackson—Trailer parked on Post Office grounds; February 14, 1966; (4) Slaughter—Post Office Building; February 14, 1966.

Madison; Tallulah—Post Office; August 13, 1966.

Ouachita; (1) Monroe—Post Office Building, Room 301; August 20, 1965; (2) West Monroe—I. B. Haynes Building, Cypress and Young Streets, February 14, 1966.

Plaquemines; (1) Buras—Post Office Building, August 10, 1965, through November 17, 1965, reopened August 31, 1967; (2) Belle Chasse—Post Office Building; November 18, 1965; (3) Belle Chasse—US Naval Air Station, Administration Building, Room 46, Office of the Senior Chief of Command; October 19, 1979.

Sabine; Many—U.S. Post Office Building; 525 San Antonia Avenue; September 27, 1974.

St. Helena; Greensburg—(1) Trailer at Post Office; College and Main Streets; August 19, 1972; (2) ASCS Office, Burrell Carter Building, Street Floor, South Main Street; October 19, 1979.

St. Landry; Opelousas—Chattau Motor Inn, 400 East Landry, the Bayou Room; December 5, 1979.

West Feliciana; (1) Saint Francisville—trailer at Post Office; November 3, 1965, through January 7, 1966; (2) Saint Francisville—Post Office Building; January 8, 1966; (3) Weyanoke—trailer located on State Highway 66 approximately 0.3 mile South of Weyanoke; February 14, 1966.

Mississippi County; Place for filing; Beginning date Adams; Prentiss Inn, U.S. 61 S, Natchez, Mississippi 39121; [phone]/25; September 17, 1991.

Amite; (1) Liberty—Walsh Building, Main Street, second floor; April 3, 1967; (2) Gloster—Ivey Building, First Street; July 29, 1967.

Benton; Ashland—Post Office Building; October 1, 1965.

Bolivar; Cleveland—Post Office Building; October 1, 1965.

Carroll; (1) Carrollton—Post Office Building, Main Street, January 4, 1966, through March 22, 1968; (2) North Carollton—Van Meter Lumber Co. Building, George Street, March 23, 1968.

Chickasaw; U.S. Office of Personnel Management, 75 Spring Street SW, Room 905, Atlanta, Georgia, 30303; 1 [phone]; August 3, 1999.

Claiborne; (1) Port Gibson—McFatters Drug Store, Second Floor, 618 Main Street; April 16, 1966, through October 9, 1969; (2) Port Gibson—Federal Building, Room 111; October 10, 1969.

Clay; (1) West Point—Post Office Building; October 1, 1965; (2) Pheba—rear of Champion Grocery Store; July 21, 1967.

Coahoma; Clarksdale—Post Office Building; October 1, 1965.

Copiah; Hazelhurst—W.S. Henley Building, 122 South Lowe Street; December 13, 1983.

Covington; Collins—McLauren Building, FHA Conference Room; August 10, 1979.

De Soto; (1) Walls—U.S. Post Office; November 8, 1965, through January 4, 1966; (2) Hernando—U.S. Post Office; January 5, 1966; (3) Olive Branch—second floor above Post Office; July 22, 1967.

Forrest; (1) Hattiesburg—U.S. Courthouse, corner of Pine and Forrest Streets, Room 6; June 8, 1967; (2) Petal—108 Ninth Avenue; September 16, 1967.

Franklin; Meadville—Old Halford Building, Highway 84 East, one block from city square; April 3, 1967.

Greene; Leakesville—FHA Conference Room, New Bank Annex, Main and Lafayette Street; August 10, 1979.

Grenada; (1) Grenada—Post Office Building; July 22, 1966, through August 7, 1966; (2) Grenada—639 Union Street; August 8, 1966, through October 9, 1969; (3) Grenada—U.S. Post Office, basement, October 10, 1969; (4) Tie Plant—trailer at site of Horseshoe Store two blocks west of Tie Plant School on dirt road; September 9, 1966.

Hinds; (1) Jackson—301 Building, 301 North Lamar Street; November 8, 1965, through January 2, 1966; (2) Jackson—Post Office Building, 245 East Capitol Street; January 3, 1966; (3) Jackson—848 Lynch Street; June 22, 1966; (4) Raymond—U.S. Post Office; November 8, 1965.

Holmes; (1) Lexington—U.S. Post Office; November 8, 1965; (2) Cruger—U.S. Post Office; July 29, 1967.

Humphreys; (1) Belzoni—Post Office Building; October 1, 1965; (2) Louise—Post Office Building; June 21, 1966; (3) Isola—trailer at Post Office, August 23, 1971.

Issaquena; Mayersville—trailer at Post Office; June 15, 1967.

Jasper; Bay Springs—trailer at New Post Office; April 16, 1966.

Jefferson; Fayette—Ball Drug Store Building, Main Street; November 8, 1965.

Jefferson Davis; (1) Prentiss—Magnolia Courts, intersection of U.S. Highway 84 and State Highway 42, Units 21 through 24; August 25, 1965, through August 26, 1965; (2) Prentiss—Post Office Building; August 27, 1965.

Jones; (1) Laurel—Federal Building, Room B-8; August 20, 1965; (2) Ellisville—102 Jasmine Street; September 16, 1967.

Kemper; DeKalb—U.S. Post Office; Lobby; Seventh Street and Eighth Avenue; November 4, 1974.

Leake; U.S. Office of Personnel Management, 75 Spring Street SW, Room 905, Atlanta, Georgia 30303; 1 [phone]; August 3, 1999.

Leflore; (1) Greenwood—Post Office Building; August 10, 1965; (2) Minter City—trailer on lot on northwest side of Post Office; June 6, 1967.

Lowndes; Columbus—Ramada Inn, Room 153, Highway 45 North; August 22, 1983.

Madison; Canton—285 Peace Street; August 10, 1965.

Marshall; Holly Springs—Post Office Building; August 8, 1967.

Monroe; Sheliane Motel, Room 44, Highway 45 N, Aberdeen, Mississippi, 39730; [phone]/2193; September 17, 1991.

Neshoba; Philadelphia—U.S. Post Office; November 8, 1965.

Newton; (1) Newton—Post Office Building; January 4, 1966; (2) Decatur—building on Fourth Avenue across street from U.S. Post Office; July 29, 1967.

Noxubee; (1) Macon—Post Office Building, Basement, Room 1; April 16, 1966; (2) Brooksville—Jourdan Building, Front Street; July 29, 1967.

Oktibbeha; Starkville—Post Office Building, 302 University Drive; April 3, 1967.

Pearl River; Picayune—Community Recreation Center; Library; Rosa and Beech Streets; June 8, 1974.

Quitman; Marks—Corp of Engineers, Rogers Road; October 29, 1980.

Rankin; (1) Brandon—Rankin Building, intersection of U.S. Highway 80 and State Highway 18; April 16, 1966, through August 4, 1966; (2) Brandon—Nettles Drug Store Building, East Government Street; August 5, 1966 through January 31, 1971; (3) Brandon—280 Government Street; February 1, 1971.

Scott; Best Western, room 130, Interstate 20 and Highway 251, Forest, Mississippi, 39074; [phone] or 3950; May 18, 1993.

Sharkey; Rolling Fork—102 Elm Street; June 14, 1967.

Simpson; (1) Mendenhall—Post Office Building; January 4, 1966; (2) Magee—Post Office Building, Ninth Avenue (between Eighth and Ninth Streets); January 10, 1966.

Sunflower; (1) Indianola-Post Office Building; May 2, 1967; (2) Ruleville-U.S. Post Office, 120 South Ruby Avenue; June 16, 1983.

Tallahatchie; (1) Charleston—103 Market Street; August 23, 1971; (2) Sumner—Abbey Building, East Court Square; August 23, 1971.

Tunica; Tunica—Department of Agriculture Building, Agricultural Conservation and Stabilization Service; South Side, Court Square; November 3, 1975.

Warren; Vicksburg—Post Office and Courthouse Building, Crawford and Monroe Streets; January 4, 1966.

Washington; Greenville—Room 204A Federal Building, Main Street and Poplar Street; August 8, 1983.

Wilkinson; (1) Woodville—Post Office Building; August 8, 1967, to August 24, 1967; (2) Woodville—Odd Fellows Building; August 24, 1967.

Winston; Louisville—Post Office Building; Basement, Room 6; April 16, 1966.

Yazoo; Yazoo City, 100 South Main Street; November 2, 1971.

New Mexico County; Place for filing; Beginning date.

Chavez; Federal Building, 5th and Richardson Street, Roswell, New Mexico; December 17, 1984.

Cibola; U.S. Forest Service, Mt. Taylor Ranger District, Cibola National Forest, 201 Roosevelt, Grants, New Mexico; December 17, 1984.

Curry; Main Post Office, 417 Gidding, Room 203, Clovis, New Mexico; December 17, 1984.

McKinley; Bureau of Indian Affairs, Eastern Navajo Agency, P.O. Box 328, Crowpoint, New Mexico (25 miles north of Thoreau, 1 mile west of State Road 57); Bureau of Indian Affairs, Navajo Area Office, Federal Building, 3rd and Hill Streets, Gallup, New Mexico; December 17, 1984.

Otero; U.S. Forest Service, Lincoln National Forest, Federal Building, 11th and New York Streets, Alamogordo, New Mexico; December 17, 1984.

Sandoval; Mobile unit on parking lot behind U.S. Post Office, Camino del Pueblo Road, Bernalillo, New Mexico; U.S. Forest Service, Cuba Ranger District, San Fe National Forest, State Highway 126 and South Main, Cuba, New Mexico. December 17, 1984.

New York County; Place for filing; Beginning date

Bronx, Kings, and New York Counties, New York; 26 Federal Plaza, Room 29108, New York, New York.

North Carolina County; Place for filing; Beginning date

Edgecombe; Tarboro—Room B3, U.S. Post Office, 525 Main Street, Tarboro, North Carolina; May 4, 1984.

South Carolina County; Place for filing; Beginning date

Bamberg; Room 6, Farmers Home Administration, J. Carl Kershe Agriculture Building, Calhoun Street, Bamberg, South Carolina. October 10, 1984.

Calhoun; Room 5, 2nd Floor, 111 Harry C. Raysor Drive, St. Mathews, South Carolina. September 28, 1984.

Chester; Chester Motor Lodge, Room 161, West End St. at By-pass, Chester, SC 29706, [phone].

Clarendon; Manning—Federal Building; November 8, 1965.

Colleton; Soil Conservation Service, Room 203, 119 Benson Street, Walterboro, South Carolina. October 10, 1984.

Darlington; Darlington—U.S. Post Office, 201 Pearl Street; November 7, 1978.

Dorchester; St. George—U.S. Post Office; November 8, 1965.

Hampton; Farmers Home Administration, 1st Floor, 1003 Elm Street, Hampton, South Carolina. October 10, 1984.

Marion; Marion—U.S. Post Office, 201 South Main Street, Conference Room; June 27, 1978.

Richland; Room 1466, Strom Thurmond FOB, 1835 Assembly Street, Columbia, South Carolina. September 28, 1984.

Williamsburg; ASCS Service Center, 208 Short Street, Kingstree, South Carolina. September 28, 1984.

Texas County; Place for filing; Beginning date

Atascosa; Pleasanton—Office of USDA, 803 North Bryant; October 29, 1980.

Bee; Beeville—Agriculture Plant and Animal Inspection Service; Basement, U.S. Post Office, 111 N. St. Mary's Street; November 2, 1976.

Crockett; Ozona—Agricultural Stabilization and Conservation Office, 801 Avenue E; August 12, 1978.

Dallas; Dallas—OPM, Room 6B3, 1100 Commerce Street, Dallas, Texas, April 4, 1984.

El Paso; El Paso—2211 East Missouri Avenue, Suite N300; November 7, 1978.

Fort Bend; Richmond—Agricultural Stabilization Conservation Office; May 1, 1976.

Frio; Pearsall—Federal Building, 411 East Colorado Avenue; November 2, 1976.

Galveston; 5914 Seawall Boulevard, Galveston, Texas 77551, [phone]; December 9, 1996.

Hidalgo—101 East 14th (West Entrance), Mission, Texas, 78572, [phone], November 8, 1988.

Jefferson; 1610 I-10 South, Beaumont, Texas 77707, [phone]; December 9, 1996.

La Salle; Cotulla—U.S. Border Patrol Station, Federal Building, North Main Street; November 2, 1976.

Medina; Hondo—Agricultural Stabilization Conservation Office; 1703 Avenue K; May 1, 1976.

Reeves; Pecos—U.S. Post Office, U.S. Attorneys Office, Room 301; May 6, 1978.

Uvalde; Uvalde—Agricultural Stabilization Conservation Office; 119 West South Street; May 1, 1976.

Wilson; Floresville—Agricultural Stabilization Conservation Office; May 1, 1976.

Forms of Application alabama Front Form approved Budget Bureau No. 50-R359 Application To Be Listed Under the Voting Rights Act of 1966 State of AlabamaCounty of Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you.

1. Name _______ (First) _______ (Middle) _______ (Last)

2. Age _____

3. Address ______ (RFD or Street Number) _____ (Street) _____ (City or Town) _____ (State)

4. How long have you lived in Alabama?

5. How long have you lived at the above address?

6. What is your precinct? ___ or ward? ___

7. Are you now (1) on active duty in the Armed Forces of the United States or the Alabama National Guard, (2) an employee of the United States or the State of Alabama, or (3) a seaman or college student? ___ □ Yes□ No

8. (a) Are you now registered to vote in Alabama? ___ □ Yes□ No

(b) Are you now listed under the Voting Rights Act? ___ □ Yes□ No

9. Are you a citizen of the United States and of the State of Alabama? ___ □ Yes□ No

Former Address

10. Have you ever been convicted of a crime other than a traffic violation? ____ □ Yes□ No

11. Have you ever been declared legally insane by a court? ___ □ Yes□ No

Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. Stop Here. Take the Form to the Examiner

I do solemnly swear (or affirm) that the information I have provided is true and correct to the best of my knowledge, information, and belief. I do further personally swear (or affirm) that I will support and defend the Constitution of the United States and the Constitution of the State of Alabama; and that I do not believe in nor am I affiliated with any group or party which advocated or advocates the overthrow of the Government of the United States or of the State of Alabama by unlawful means.

Signature (or mark) of Applicant Sworn to (or affirmed) and subscribed before me on this date Examiner U.S. Office of Personnel Management CSC Form 805-A † August 1965 Back Do not write on this side—for use by examiner Additional Information Items

2. If applicant shows his age to be under 21, write in his date of birth

4. If applicant shows that he has not lived in Alabama for one year, will he have lived in Alabama for one year by the date of the next election? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former Address

5. If applicant shows that he has not lived at his present address for six months, will he by the date of the next election have:

Lived in the same county for six months? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former Address

Lived in his precinct or ward for three months? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former Address

Lived in the same city or town for three months? ___ □ Yes□ No

If yes, write in the date residence began

__________

7. If applicant answers yes, is his residence in Alabama and in his county for temporary purposes only? ___ □ Yes□ No

If yes, write in his occupation

8. (a) If applicant shows that he is now registered to vote in Alabama, write in the county where he is registered

(b) If applicant shows that he is now listed under the Voting Rights Act, write in the county where he is listed ______ and certificate number if available ______.

10. If applicant answers yes, name the crime __________ Where and when convicted? __________ Was the conviction for a disqualifying crime? ____

□ Yes□ No

If a disqualifying crime, has applicant been pardoned with restoration of his right to vote? ___ □ Yes□ No

If so pardoned, how and when?

11. If applicant answers yes, has he subsequently been declared legally sane or competent by a court? ___ □ Yes□ No

If yes, when and by what court?

Certificate of Eligibility Issued-No. _____ Notification of Ineligibility Issue-No. _____

georgia Front Application To Be Listed Under the Voting Rights Act of 1965 Form approved Budget Bureau No. 50-R359 State of GeorgiaCounty of Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you.

1. Name _______ (First) _______ (Middle) _______ (Last)

2. Age _____

3. Address ______ (RFD or Street Number) _____ (Street) _____ (City or Town) _____ (State)

4. How long have you lived in Georgia?

5. How long have you lived at the above address?

6. What is your election district?

7. Are you now on active duty in the Armed Forces of the United States? ____ □ Yes□ No

8. (a) Are you now registered to vote in Georgia? ___ □ Yes□ No

(b) Are you now listed under the Voting Rights Act? ___ □ Yes□ No

9. Are you a citizen of the United States and of the State of Georgia? ___ □ Yes□ No

10. Have you ever been convicted of a crime other than a traffic violation? ____ □ Yes□ No

11. Have you ever been declared legally insane or idiotic by a court? ___ □ Yes□ No

Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. Stop Here. Take the Form to the Examiner

I do solemnly swear (or affirm) that I am not registered to vote under any other name; that I have correctly answered the questions appearing elsewhere on this application; that the information contained elsewhere on this application is true.

Signature (or mark) of applicant Sworn to (or affirmed) and subscribed before me this date Examiner U.S. Office of Personnel Management CSC Form 805-G † August 1965 Back Do not write on this side—for use by the Examiner Additional Information Items

2. If applicant shows his age to be under 18, will he be 18 by the date of the next election? ___ □ Yes□ No

Write in his date of birth

4. If applicant shows that he has not lived in Georgia for one year, will he have lived in Georgia for one year by the date of the next election? ___ □ Yes□ No

If yes, write in date residence began

__________

Former address

5. If applicant shows that he has not lived at his present address for six months, will he have lived within the same county for six months by the date of the next election? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former address

7. If applicant answers yes, is his residence in Georgia and in his county for temporary purposes only? ___ □ Yes□ No

8. (a) If applicant shows that he is now registered to vote in Georgia, write in the county where he is registered

(b) If applicant shows that he is now listed under the Voting Rights Act, write in the county where he is listed ______ and certificate number if available

10. If applicant answers yes, name the crime __________ Where and when convicted? __________ Was the conviction for a disqualifying crime? ____

□ Yes□ No

If a disqualifying crime, has applicant been pardoned? ___□ Yes□ No

If so pardoned, where and when?

11. If applicant answers yes, has he subsequently been declared legally sane or competent by a court? ___ □ Yes□ No

If yes, when and by what court?

Certificate of Eligibility Issued—No. _____ Notice of Ineligibility Issued—No.

louisiana Front Form approved Budget Bureau No. 50-R359 Application To Be Listed Under the Voting Rights Act of 1965

State of Louisiana Parish of

Instructions to the applicant: Please fill out this side of this form. If you need help in answering questions 1 through 13, the Examiner will help you.

1. Name _______ (First) _______ (Middle) _______ (Last)

2. Age _____

3. Address ______ (RFD or Street Number) _____ (Street) _____ (City or Town) _____ (State)

4. How long have you lived in Louisiana?

5. How long have you lived at the above address?

6. What is your precinct and ward?

7. Are you now (1) on active duty in the Armed Forces of the United States or the Louisiana National Guard, (2) an employee of the United States or the State of Louisiana, or (3) a seaman or college student? ___ □ Yes□ No

8. (a) Are you now registered to vote in Louisiana? ___ □ Yes□ No

(b) Are you now listed under the Voting Rights Act? ___ □ Yes□ No

9. Are you a citizen of the United States and of the State of Louisiana? ___ □ Yes□ No

10. Have you ever been convicted of a crime other than a traffic or game violation? ___ □ Yes□ No

11. Have you ever been dishonorably discharged from or are you a deserter from the Louisiana National Guard or militia or the military service of the United States? ___ □ Yes□ No

12. Have you ever been declared legally insane or incompetent by a court? _____

□ Yes□ No

13. Are you now living in a charitable home or institution? ___ □ Yes□ No

14. What is your political party preference?

Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. Stop Here. Take the Form to the Examiner

I do solemnly swear (or affirm) that I will faithfully and fully abide by all of the laws of the State of Louisiana, that I am well disposed to the good order and happiness of the State of Louisiana and of the United States, and that the information I have provided is true to the best of my knowledge and belief.

Signature (or mark) of applicant Sworn to (or affirmed) and subscribed before me this date Examiner U.S. Office of Personnel Management CSC Form 805-L † August 1965 Back Do not write on this side—For use by examiner Additional Information Items

2. If the applicant shows his age to be under 21, will he be 21 by the date of the next election? ___ □ Yes□ No

Write in his date of birth

4. If the applicant shows that he has not lived in Louisiana for one year, will he have lived in Louisiana for one year by the date of the next election? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former Address

5. If applicant shows that he has not lived at his present address for six months, will he by the date of the next election have:

Lived in the same parish for six months? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former Address

Lived in this precinct for three months? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former Address

Lived in the same town or city for four months? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former Address

7. If applicant's answer is yes, is his residence in Louisiana and in his parish for temporary purposes only? ___

□ Yes□ No

If yes, write in his occupation

8. (a) If applicant shows that he is now registered to vote in Louisiana, write in the parish where he is registered:

(b) If applicant shows that he is now listed under the Voting Rights Act, write in the parish where he is listed _______ and certificate number if available

10. If applicant answers yes, name the crime

Where and when convicted?

Was the conviction for a disqualifying crime? ____ □ Yes□ No

If a disqualifying crime, has applicant been pardoned with express restoration of the right to vote? ___ □ Yes□ No

If so pardoned, how and when?

11. If applicant answers yes, write in whether dishonorably discharged or a deserter?

If dishonorably discharged, has he been reinstated? ___ □ Yes□ No

If yes, when and where?

If a deserter, has he returned to his command and made up his lost time? _____

□ Yes□ No

If yes, when and where?

12. If applicant shows that he has been declared legally insane or incompetent by a court, has he subsequently been declared legally sane or competent by a court? ____

□ Yes□ No

If yes, when and what court?

13. If the applicant shows that he is now living in a charitable home or institution, is he disqualified? ___ □ Yes□ No

Certificate of Eligibility Issued—No. Notice of Ineligibility Issued—No. mississippi Front Form approved Budget Bureau No. 50-RO436 Application to be Listed Under the Voting Rights Act of 1965 State of Mississippi, County of Instructions to the Applicant: Please fill out both sides of this form. If you need help in answering any question, the Examiner will help you.

1. Name _______ (First) _______ (Middle) _______ (Last)

2. Date of Birth

3. Social Security No

4. Are you a citizen of the United States? ___ □ Yes□ No

5. What is your present residence address and each place you have resided during the past year, stating when you lived at each place?

(a) Present address __________ From ______ to date.

(b) Previous address __________ From ______ to ______

(c) Previous address __________ From ______ to ______

(If you need additional space, use the back side of this form.)

6. What is your election district? ______ Beat _______ Precinct _______ City Ward _____

7. Are you now registered to vote in Mississippi? ___ □ Yes□ No

(a) When:

(b) What county:

(c) Address at that time:

8. Have you ever been convicted of a crime of murder, rape, bribery, theft, arson, obtaining money or goods under false pretenses, perjury, forgery, embezzlement or bigamy? ___ □ Yes□ No

(a) Which crime?

(b) When and where?

Has the right to vote been restored? ___ □ Yes□ No

If yes, when:

9. Have you ever been declared legally insane by a court? ___ □ Yes□ No

If yes, when:

Where:

(a) When and where declared competent by a court:

10. (a) If you have a current driver's license, state its number and the address shown thereon:

(b) If you own a motor vehicle, state license tag number and the county and State in which the vehicle is registered for ad valorem and road and bridge privilege tax purposes:

(c) If you filed an income tax return for the year immediately past, state the address on your most recent income tax return:

(d) If you own real property, state its location:

(e) If you are receiving homestead exemption on any real property, state the location of all such property:

(f) If you are currently employed, state the location of the place where you actually report for work:

(g) State the location of any church affiliation or location of any other religious groups of which you are a member:

(h) State the location of the greater amount of your personal possessions:

(i) If you have a telephone, state its location and number:

11. Do you intend to make this precinct and county your fixed habitation, for a definite or indefinite length of time, to which you intend to return whenever absent? ___ □ Yes□ No

Any willful false statement on this application is a Federal crime punishable by fine or imprisonment. Stop Here. Take the Form to the Examiner

I do solemnly swear (or affirm) that I am at least eighteen (18) years old (or will be before the next election in this county), and that I am now in good faith a resident of this state and of __________ election precinct in this county and that I am not disqualified from voting by reason of having been convicted of any crime named in the Constitution of this state as a disqualification to be an elector; that I have truly answered all questions propounded to me in the foregoing application for registration; and that I will faithfully support the Constitution of the United States and of the State of Mississippi, and will bear true faith and allegiance to the same. So help me God.

Signature (or mark) of applicant Sworn to (or affirmed) and subscribed before me this date Examiner U.S. Office of Personnel Management Certificate of Eligibility Issued—No. Notice of Ineligibility Issued—No. CSC Form 805-M Revised February 1973 Back Do not write on this side—for use by examiner Additional Information Items

2. If applicant shows his age to be under 21, will he be 21 by the date of the next election? ___ □ Yes□ No

Write in his date of birth

5. If applicant shows that he has not lived in Mississippi for two years, will he have lived in Mississippi for two years by the date of the next election? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former address

6. If applicant shows that he has not lived at his present address one year, will he by the date of the next election have:

Lived in the same election district for one year? ___ □ Yes□ No

If applicant is a minister or minister's wife, for 6 months? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former address

Lived in the same city, town, or village for one year? ___ □ Yes□ No

If applicant is a minister or minister's wife, for 6 months? ___ □ Yes□ No

If yes, write in the date residence began

__________

Former address

8. (a) If applicant shows that he is now registered to vote in Mississippi, write in the county where he is registered

(b) If applicant shows that he is now listed under the Voting Rights Act, write in the county where he is listed ________ and certificate number if available

10. If applicant answers yes, was the conviction for bribery, burglary, theft, arson, perjury, forgery, embezzlement, bigamy, or obtaining money or goods under false pretenses? ___ □ Yes□ No

If yes, answer the following questions:

Which crime?

When and where convicted?

Has right to vote been restored by the legislature?

If so restored, when?

11. If applicant answers yes, has he subsequently been declared legally sane or competent by a court? ___ □ Yes□ No

If yes, when and by what court?

Certificate of Eligibility Issued—No. Notice of Ineligibility Issued—No. south carolina Front Form approved Budget Bureau No. 50-R359 Application To Be Listed Under the Voting Rights Act of 1965 State of South Carolina County of Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you.

1. Name _______ (First) _______ (Middle) _______ (Last)

2. Age _____

3. Address ______ (RFD or street number) _____ (Street) _____ (City or town) _____ (State)

4. (a) Are you a minister in charge of an organized church or the spouse of such a minister ___ □ Yes□ No

(b) Are you a teacher in a public school or the spouse of such a teacher ___ □ Yes□ No

5. How long have you lived in South Carolina

6. How long have you lived at the above address

7. What is your ward and precinct

8. Are you now (1) a student, (2) a seaman, (3) an employee of the United States, or (4) on active duty in the Armed Forces of the United States ___ □ Yes□ No

9. (a) Are you now registered to vote in South Carolina ___ □ Yes□ No

(b) Are you now listed under the Voting Rights Act ___ □ Yes□ No

10. Are you a citizen of the United States and the State of South Carolina ____

□ Yes□ No

11. Have you ever been convicted of a crime other than a traffic violation ____ □ Yes□ No

12. Have you ever been declared legally insane, idiotic, or mentally incompetent by a court ___ □ Yes□ No

13. Are you a pauper receiving all your support from your county, town, or city government ___ □ Yes□ No

Any willful false statement on this application is a Federal crime punishable by fine or imprisonment Stop Here—Take the Form to the Examiner

I hereby solemnly swear (or affirm) that the information I have provided is true to the best of my knowledge and belief and I so certify.

Signature (or mark) of applicant Sworn to (or affirmed) and subscribed before me this date Examiner U.S. Office of Personnel Management CSC Form 805-S, October 1965 Back Do not write on this side—for use by examiner Additional Information Items

5. If the applicant shows that he has not lived in South Carolina for one year, will he have lived in South Carolina for one year by the next election (or six months if applicant is a minister in charge of an organized church or a teacher in a public school, or the spouse of either) ___ □ Yes□ No

If yes, write in the date when he began to live in South Carolina

Former address

6. If the applicant (other than a minister, teacher, or spouse of either) shows that he has not lived at the same address for six months, will he by the date of the next election have:

Lived in the same county for six months ___ □ Yes□ No

If yes, write in the date when he began to live in the county

Former address

Lived in the same city or town for four months ___ □ Yes□ No

If yes, write in the date when he began to live in the city or town

Former address

Lived in the same precinct for three months ___ □ Yes□ No

If yes, write in the date when he began to live in the precinct

Former address

8. If applicant answers yes, is his residence in South Carolina and in his county for temporary purposes □ Yes□ No

If yes, write in his occupation

9. (a) If applicant shows that he is now registered to vote in South Carolina, write in the county where he is registered

(b) If applicant shows that he is now listed under the Voting Rights Act, write in the county where he is listed ________ and certificate number if available

11. If applicant answers yes, name the crime

Where and when convicted

Was the conviction for a disqualifying crime ___ □ Yes□ No

If a disqualifying crime, has the disqualification been removed by pardon of the Governor ___ □ Yes□ No

If so pardoned, where, when and by whom

12. If the applicant shows that he has been declared legally insane, idiotic, or mentally incompetent by a court, has he subsequently been declared legally sane or mentally competent by a court ___ □ Yes□ No

If yes, when and by what court

13. If the applicant shows that he is a pauper receiving all of his support from his county, town, or city, write details here

Certificate of eligibility issued—No.

Notice of ineligibility issued—No.

texas Front Form approved OMB No. 50R0592 Voting Rights Act Application

The information requested below is for the purpose of determining whether you are eligible to vote. If you are found eligible to vote, your name will be certified to appropriate state officials for addition to the official voting lists. The solicitation of this information for this purpose is authorized by the Voting Rights Act of 1965, as amended. While you are not required to respond, your cooperation is needed if you wish to be found eligible to vote.

Instructions to the Applicant: Please fill out this side of this form. If you need help in answering any question, the Examiner will help you.

1. Name _______ (First) _______ (Middle) _____ (Last)Maiden surname if married woman: _____

2. Sex: _____

3. Permanent residence address: __________ (Street and Apt. No., if any, or Route No. or location (Not P.O. Box)) _______ (City) _____ (ZIP code)

4. Election Precinct (if known):

5. Mailing address if different from above: __________ (Street or P.O. box) _____ (City) _____ (State) _____ (ZIP code)

6. Birthplace: City _____ or county _____ State _____ or foreign country _____

7. Birth date: Month ___ Day ___ Year ___If naturalized, give court of naturalization or its location:

8. Former registration: If now registered in another Texas County: __________ (Name of county)

Last residence address: __________ (Street and apt. No., if any) _____ (City) _____ (State) _____ (ZIP code)

The disclosure of social security number and telephone number is voluntary. Failure to state either or both numbers will NOT result in your application being deficient. The numbers will be used only to maintain the accuracy and integrity of the registration records.

Social Security Number _____ Telephone Number _____

Any willful false statement on this application is a Federal crime punishable by fine or imprisonment.

STOP HERE.

TAKE THE FORM TO THE EXAMINER.

I do solemnly swear (or affirm) that I, the applicant, am 18 years of age or over, or will be 18 years of age or older within 60 days after applying for registration, and am a citizen of the United States, hold legal residence in this county, have met all legal requirements, and I understand that the giving of false information to procure the registration of a voter is a felony.

Signature (or mark) of applicant

Signature of agent*

*Agent must be a registered voter, and must be only: (Circle one applicable) Husband—Wife—Mother—Father—Son—Daughter

Sworn to (or affirmed) and subscribed to me this date

Examiner

U.S. Office of Personnel Management CSC FORM 805-T April 1976 Back Do not write on this side—For use by examiner Additional Information Items

Texas law states that a person convicted of a felony and not subsequently pardoned, and a person adjudicated a lunatic or idiot and not subsequently adjudicated competent, are not qualified to vote. Therefore, the following questions must be asked.

A. Have you ever been convicted of a felony: ___ □ Yes□ No

If applicant answers yes, name the crime

Where and when convicted

Was the conviction for a disqualifying crime: ___ □ Yes□ No

If a disqualifying crime, has applicant been pardoned with restoration of his right to vote: ___ □ Yes□ No

If so pardoned, how and when

B. Have you ever been declared to be an idiot or a lunatic by a court: ___ □ Yes□ No

If applicant answers yes, has he subsequently been declared legally sane or competent by a court: ___ □ Yes□ No

If yes, when and by what court

Certificate of eligibility issued—No.

Notice of ineligibility issued—No.