Precinct Election Official Application - Surry County Board Of Elections (Page 2 of 2) in pdf

Surry County Board of Elections

STUDENT ELECTION ASSISTANTS

Precinct Election Official Application

Enrollment / Academic Status

I am applying for the

Verification (Required):

Last Name

First Name

Name you go

by:

position of:

Name of Principal/Director or Educator:



Gender

Date of Birth

Voter Registration # (if known)

Party Affiliation

Chief Judge

 M  F

__________________________________



Judge



Democrat



Assistants

Republican

School Name: ______________________

Home Address



Student Asst.

Unaffiliated



School Address: ____________________



OneStop

Libertarian



Not Registered

__________________________________

Volunteer

Daytime Phone: ____________________

Alternate

Phone:

Email address:

Home

Phone:

Cell

Phone:

Email: ____________________________

Signature: _________________________

Please check the appropriate box:

By my signature above, I am recommending this student



I will be able to attend a 3-hour training session(s) before each election:

Yes

to be a student election assistant and certify that he/she is



enrolled and has an exemplary academic record as

I have my own transportation to and from the polling place on Election Day:

Yes

defined by this institution.



I am computer literate or I am willing to learn and be trained:

Yes



I am physically able to lift 50 lbs.:

Yes

Parental Permission (Required):



I am able to work continuously from 5:30am until at least 8:30pm on Election Day:

Yes



I understand I may be required to assist other poll workers in my precinct on the eve of the election:

Yes

Parent

Guardian

Legal Custodian



I am currently a registered voter and resident of Surry County:

Yes

Name: ____________________________



I am able to serve in an impartial manner and will not voice my own political views while working:

Yes



I am willing to work outside my precinct if needed:

Yes

Address: __________________________

In regard to technology (setting up & operating a laptop / printer, etc.), my comfort level can best be described

as:q

__________________________________



Fearless

Confident with Training

Somewhat Nervous

Uneasy, never use computers

Daytime Phone: ____________________

NOTICE TO APPLICANT— PLEASE READ BEFORE YOU SIGN BELOW:

Persons appointed by the Surry

Email: ____________________________

County Board of Elections to these positions must be registered voters (or at least age 17) and legal U. S. residents of

the county or precinct, of good repute, and able to read and write legibly. Your signature indicates you have read this

brochure and understand the information presented. Your signature does not guarantee you will be appointed as a

Signature: _________________________

Precinct Election Official. The Surry County Board of Elections may remove you as a precinct election official for

misbehavior or neglect of duty at their discretion. You will be contacted if selected

appointment.

for

By my signature above, I consent for this student to be

absent from school attendance on Election Day and that I

allow him/her to perform service as a student election

assistant.

Applicant’s Signature

:_______________________________________________________

Date

:________________

Date approved by CBE office:

Precinct Election Official Application - Surry County Board Of Elections Page 2

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