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2. PERSONAL INFORMATION
4. Full Name*
5. Pronouns
7. Preferred Name
9. Date of Birth (MM/DD/YYYY)*
11. Email Address*
13. Street Address*
15. City*
16. State*
17. Zip*
19. Primary Phone*
20. Secondary Phone
22. What city or township are you registered in?*
23. Pct #
24. Ward #
26. County of:*
28. Political Party Affiliation*

    (State Election Law requires you must select a political party. Independent is not a party.)

    1. Republican
    2. Democratic
    3. Libertarian
    4. U.S. Taxpayers
    5. Green
    6. Natural Law
    7. Working Class
30. Have you ever been convicted of a felony or election crime?*

    1. Yes
    2. No
32. EDUCATION AND EXPERIENCE INFORMATION
34. Education Background (include highest grade completed or degree held)
36. Employment Background (include current or last place of employment and type of work performed)
38. Languages other than English that you speak (if any)
40. Please rate your computer experience (data look-up, database processing, creating PDFs, etc.):

    1 = not experienced, 5 = very experienced

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
42. Past experience as an election inspector, if any (include name of jurisdiction):
44. Do you have transportation?*

    1. Yes
    2. No
46. Will you work at any polling place?

    1. Yes
    2. No
47. If not, please explain:
49. 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. Type your name in the signature box below to certify.
51. Signature*
52. Date (MM/DD/YYYY)*
54. * 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.
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56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field