Michigan Election Inspector Application - Clare County printable pdf download

State of Michigan Election Inspector Application

(Complete in your own handwriting and return to your local City/Township Clerk)

personal information

Full Name ____________________________________________________________________________

Date of Birth ________/________/_______ Email Address _____________________________________

Home Address ________________________________________________________________________

Phone #’s Home: _____________________ Work: ____________________ Cell: ___________________

Registered in  City or Township of _________________________ Pct # _______ Ward # ________

County of ___________________________________________

Political Party Affiliation (REQUIRED; must be a recognized state party & may not be Independent):

 Republican  Democratic  Libertarian  U.S. Taxpayers  Green  Natural Law

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

 Yes  No

education and experience information

Education Background (include highest grade completed or degree held) ____________________________

_________________________________________________________________________________________

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

_________________________________________________________________________________________

Languages other than English that you speak (if any) ______________________________________________

Please rate your computer experience (data look‐up, database processing, creating .pdfs, etc.):

1 = not experienced, 5 = very experienced

 1  2  3  4  5

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 If not, explain: _________________________________

_________________________________________________________________________________________

signature and certification

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.

________________________________________________ ________/________/________

Signature of Applicant Date

* 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 statements reported by the news media or written statements

with a clear and unambiguous attribution to the applicant.

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

Approved by State Director of Elections (June 2015)

Michigan Election Inspector Application - Clare County