Contact/Personal Information
Your First Name  *
Your Last Name  *
Date of Birth  *
Home Address  *
Home Phone  *
Do You Have Transportation?
Registered in
If you are registered in a township, please provide the township name and precinct.
County of Residence  *
Length of Residence in county  *
To be eligible for appointment you MUST check on.
Party Affiliation
If you selected "Other", please provide the party name.
Other Party
Have you ever been convicted of a felony or election crime?
When completing your Educational Background, please include the highest grade completed or degrees held.
Educational Background *
When adding your Employment Background, please include your curent or last place of employent and type of work performed.
Employment Background *
If you have past experience as an Election Inspector, please include the name of the jurisdiction in which you served.
Election Inspector Experience *
Certification - By submitting this form, I certify that I am not a member or a known advocate* of a political party other that the party identified above. I further state that the foregoing statements are true to the best of my knowledge and belief.
Full Name  *
Date  *
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