Election Inspector Application - Walker City printable pdf download

ELECTION INSPECTOR APPLICATION

WALKER CITY

(Must be completed in your own handwriting in ink)

Name in Full_____________________________________Date of Birth_____\_____\ _____

Home Address___________________________________ Telephone #_________________

Length of Residence in City, Township, Village or School District _____________________

Registered in Precinct #______ Ward # ______ Social Security # ______-______- _______

Political Party Affiliation (to be eligible for appointment you MUST check one):

Republican Party

Democratic Party

Other Party

_____________

(Name the party)

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

Yes_____ No_____

***************************************************************************

Educational Background – (include highest grade completed or degrees held) ____________

__________________________________________________________________________

Employment Background – (include current or last place of employment and type of work

performed) _________________________________________________________________

__________________________________________________________________________

Past experience as an election inspector, if any (include name of jurisdiction)_____________

__________________________________________________________________________

Do you have transportation? Yes___No___ Will you work at any polling place? Yes___ No___

I CERTIFY THAT I am not a member or a known active advocate* of a political party other than

the party identified above. I FURTHER CERTIFY THAT the foregoing statements are true to

the best of my knowledge and belief.

_______________________________________________________ Date_____\_____\_____

SIGNATURE OF APPLICANT

* 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 election inspector. “Documented public statements” means statements reported by the

news media or written statements with a clear and unambiguous attribution to the applicant.

ANY FALSE STATEMENTS ON THIS APPLICATION WILL DISQUALIFY THE APPLICANT

Approved by State Director of Elections

Election Inspector Application - Walker City