Poll Worker Application

Support Form (#4)

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Are you are Registered Voter?

Yes

Have you ever served as an Election Board Worker?

Yes

Would you accept assignment to another town in your county?

Yes

(if you checked yes, please list below wat town(s) you prefer)

State the Political Party to which you belong?

Do you speak any other languages in addition to English?

Yes

What other languages do you speak?

Signature

Sign Here

Date

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