Election Inspector Application

Election Inspector Application
PERSONAL INFORMATION:
Full Name*
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Email*
example@example.com
Registered to Vote in the City or Township of:*
Registered to Vote in the County of: *
POLITICAL PARTY AFFILIATION:

Required; must be a recognized state party and may not be independent.
Political Party Affiliation Required; must be a recognized state party and may not be independent*

RepublicanDemocraticLibertarianU.S. TaxpayerGreenNatural LawWorking Class
Have you ever been convicted of a felony or election crime?*

YesNo
EDUCATIONAL/EXPERIENCE INFORMATION:
Education Background (highest grade completed or degree held)*
Employment Background (current or last place of employment)*
Please rate your computer experience and comfort on a scale of 1-5*
Past experience as an election inspector:*

YesNo
If yes, where:
ELECTION INFORMATION:
Position Preference:

ChairpersonElectronic PollbookInspectorAVCB
Are you, a relative, or someone in your household running for political office?*

YesNo
If yes, please indicate the office, jurisdiction and candidate’s name:
SIGNATURE AND CERTIFICATION:
I CERTIFY THAT I am not a member or a known 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*

Clear
Date*

MonthDayYear
Date
PRE-EMPLOYMENT CRIMINAL HISTORY BACKGROUND CHECK AUTHORIZATION FORM
The information solicited and provided on this form is part of the City’s pre-employment hiring process. Please note that any information provided on this form is for criminal background check purposes only.
First Name*
Middle Initial
Last Name*
Maiden Name
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Driver’s License Number*
Gender*

MaleFemale
Race:*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
Have you resided outside the state of Michigan in the last 7 years?*

YesNo
If yes, please provide your social security number. If no, type "N/A".*

If yes, please list all cities and states lived in for the last 7 years.

	Dates	City	State

Have you ever pled guilty or no contest to felony charges?*

YesNo
Are you currently charged with a criminal offense and awaiting disposition?*

YesNo
I acknowledge The City of Mt. Pleasant will use my driver's license number and date of birth to run a criminal background and driving record status verification.*
Type name here.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Election Inspector Application

PERSONAL INFORMATION:

POLITICAL PARTY AFFILIATION:

EDUCATIONAL/EXPERIENCE INFORMATION:

ELECTION INFORMATION:

SIGNATURE AND CERTIFICATION:

PRE-EMPLOYMENT CRIMINAL HISTORY BACKGROUND CHECK AUTHORIZATION FORM