Tennessee Code Title 2. Elections § 2-2-116

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?

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?

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.