The permanent registration record shall be substantially as follows, shall contain all the information required before being signed by the registrant, and shall be witnessed as indicated on the form.
PERMANENT REGISTRATION RECORD
1.
Last Name First Name Middle Name Sex
2. Legal Residence
Number Street or Road Apt.
3. City County
4. Mailing Address if different from Legal Residence.
5. Social Security number, if any
6. Date and place of birth
7. Are you a citizen of the United States?
8. Where were you last registered to vote? City County State
9. Are you a resident of the State of Tennessee?
10. Have you ever been convicted of a crime which is a felony in this state, by a court in this state, a court in another state, or a federal court?
11. If the answer to question ten (10) is “yes,” list the crime, or crimes, for which you were convicted, and date, or dates, of conviction.
12. If the answer to question ten (10) is “yes,” have you received a pardon or had your full rights of citizenship restored by a court for all crimes listed?
State of Tennessee
ss
County of
I, being duly sworn on oath (or affirmation) declare that the above address is my legal residence and that I plan to remain at such residence for an undetermined period of time and say that to the best of my knowledge and belief all of the foregoing statements made by me are true.
Signature of Applicant
If the registrant signs by a mark, or cannot sign at all, fill in the following information:
Sworn to and subscribed to before me
this day of, 20,
Signature of Administrator of Elections or
other person taking affidavit
Official Position
Registered as voter in District Ward
Precinct effective.