Poll Worker Application

PRECINCT ELECTION OFFICIAL APPLICATION
YESNO
YESNO
YESNO
Full Legal Name*
Address*
City*
Zip Code*
Email*
example@example.com
Cell Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
DemocratRepublicanNone
Education
Complete Department if currently a city or county employee
Please contact number listed below for questions or inquires:

Republican Booth Official: (419) 213-2043

Democratic Booth Official: (419) 213-2034
Signature
Date

MonthDayYear
Date
By typing my name above, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature. My signature is proof that: Under penalty of perjury, I hereby swear or affirm that the above information is true and accurate. Further, I authorize the Lucas County Board of Elections to conduct a background check. I understand that any active warrants or felony convictions on my criminal record will result in immediate termination as a Board of Elections, election official. No person who has been convicted of a felony, or any violation of the election laws, shall serve as an election officer. Ohio Revised Code Statute 3501.27
Should be Empty:

PRECINCT ELECTION OFFICIAL APPLICATION