Election Inspector Application and Availability Form

Name

First

Last

Date of Birth (dd/mm/yyyy)

Cell Number ex. (000) 000-0000

Home Number ex. (000) 000-0000

Type N/A if you do not have a separate Home Number

Work Number ex. (000) 000-0000

Type N/A if you do not have a separate Work Number

Email

Address (Street, City, State, Zip)

You are registered in...

City of ...
Township of ...

List name of your City or Township of Registration:

List the County of your City or Township:

Political Party Affiliation (REQUIRED and must be a recognized state party and may NOT be Independent):

Have you ever been convicted of a felony or election crime?

Yes
No

Highest grade and/or degree you completed:

the Number Your

Your current or last place of employment and type of work performed:

List any languages you speak other than English (if any):

Computer Experience *

Selected Value: 1

Please rate your computer experience with database searches, database processing, creating PDFs, etc. where 1 = not experienced and 5 = very experienced

Past experience as an election Inspector, if any, including the name the jurisdictions in which you worked:

Do you have transportation?

Yes
No

Will you work at any polling place?

Yes
No

Explain your "NO" answer to the above question, if applicable

By checking this box I CERTIFY THAT I am not a member of a known active advocate* of a political party other than the party identified above.

I hereby certify that the above is true information

* A "known active advocate" of another political party is defined to mean a person who 1) is a delegate to the convention or an officer of another party; 2) is affiliated with another party through an elected or appointed government position or 3) has made documented public statements specifically supporting by name another political party or its candidates in the same calendar year as the election at which the person will serve as an inspector. "Documented public statements" means reported by the news media or written statements with a clear and unambiguous attribution to the applicant.

By checking this box I FURTHER CERTIFY the foregoing statements are true to the best of my knowledge and belief.

I hereby certify the above as true information

Todays' Date (dd/mm/yyyy)

ANY FALSE STATEMENTS MADE ON THIS APPLICATION WILL DISQUALITY THE APPLICANT.

INDICATE WHICH OF THE DATES YOU ARE WILLING TO WORK

Are you interested in being a Precinct Co-Chair?

Yes, I'm willing to be a co-chair.
No thank you, I'd prefer not to be a co-chair.
Maybe, I need more information.

Special training is provided by Ottawa County, as is supplemental Township training the day prior to an election.

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