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* indicates a required field

2. First Name*
3. Middle Name*
4. Last Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Phone Number*
13. Email Address*
15. Township or City*
    -- Select One --Calvin TownshipHoward TownshipJefferson TownshipLaGrange TownshipMarcellus TownshipMason TownshipMilton TownshipNewberg TownshipOntwa TownshipPenn TownshipPokagon TownshipPorter TownshipSilver Creek TownshipVolinia TownshipWayne TownshipCity of Dowagiac
16. Precinct #*
18. Political Party Affiliation*

    You MUST check one to be eligible for appointment)

    1. Democrat
    2. Republican
    3. U.S. Taxpayers
    4. Working Class
    5. Libertarian
    6. Green
    7. Natural Law
20. Are you a qualified and registered elector of this state?*

    1. Yes
    2. No
22. If no, are you 16 or 17 years of age?

    1. Yes
    2. No
24. Have you ever been convicted of a felony or election crime?*

    1. Yes
    2. No
26. Are you willing to work in an Absent Voter Counting Board?*

    1. Yes
    2. No
28. Are you, your spouse, or a relative within your household running for a political office?*

    1. Yes
    2. No
30. What is his or her name?
32. Which office is he/she running for?
33. Which jurisdiction is he/she running in?
35. Educational Background*

    Include highest grade completed or degrees held.

37. Employment Background*

    Include current or most recent place of employment and the type of work performed.

39. Election Inspector experience, if any:*

    If none, type "none."

41. I certify that I am not a member of or a known advocate of a political party other than the party identified above. I further certify that the facts that I provided are true to the best of my knowledge and belief.
43. Electronic Signature*
44. Date*
    Date
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

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