Tenn. Code Ann. § 2-2-116: Registration form

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 ____________________. Acts 1972, ch. 740, § 1; 1978, ch. 941, § 3; T.C.A., § 2-216; Acts 1981, ch. 337, § 1; 1981, ch. 345, § 5; 1989, ch. 274, § 2; 1994, ch. 919, §§ 13-15; 2001, ch. 413, § 12; 2002, ch. 698, § 4; 2008 , ch. 928, § 2.

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

Last Name First Name Middle Name Sex

2. Legal Residence ______________ Number Street or Road Apt.

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

. 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 ____________________.

______________

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 ____________________.