POLL MANAGER’S APPLICATION

NAME: _________________________________ Registration Cert. #: ___________________

ADDRESS: ______________________________ Social Security #: _____________________

Street Name & Number

________________________________________ Precinct registered: ____________________

City State Zip Code

MAILING ADDRESS: _____________________ Home Phone #: _______________________

P. O. Box

________________________________________ Business Phone #: _____________________

City State Zip Code

I would be willing to serve as clerk (pick up and return supplies): Yes No

Do you prefer to work in your home precinct? Yes No

I would be willing to work in any precinct as needed: Yes No

I would prefer to work at the following precincts: 1. _______________________________

2. _______________________________

3. _______________________________

Person to contact in case of an emergency: ________________________ Phone: ____________

My family doctor is: ___________________________________________Phone: ___________

In the event of an emergency, I prefer to be taken to the following hospital: _________________

I understand that I will serve as an impartial Poll Manager/Clerk in the precinct regardless of my affiliation with
any party or candidate. I will not try to influence the voters in any way or give out literature of any kind relating to
candidates and their positions on issues. I understand that I must attend a training session that will be offered by
the Registration & Elections Office prior to each election to become certified. I will to the best of my ability follow
the election laws and procedures set forth in conducting any election that I may serve in.

_______________________________________ __________________________________________
DATE SIGNATURE OF APPLICANT