This form must be completed and returned to the Police and Public Safety Department, 422 N. Washington Square, Gannon Vocational-Technical Center, Room 2800 by 12 Noon on Monday, January 6, 2003.

Please print or type.

Name:___________________________________________________________________

Birth date: ______________________________

Home Phone: ________________________  Business Phone:________________________

Residence _________________________________________________________________________
                               (Street Address)                                                         (City)                         (Zip Code)

City of/     Township of:___________________________________________________

County of: __________________________Precinct no____________________ Ward no. _________

Resident of County for __________ years.  Resident of Michigan for ____________ years.

I am registered and qualified to vote at this address:              Yes       No

Applicant's signature: ________________________________________________________________

Subscribed and sworn before me this ____________ day of_______________________, 200__

Signature of Notary Public:____________________________________________________

Name of notary: _________________________________ County:_______________________

Commission expires:_________________________________________________________
                                                                           (Print, type or stamp)