"Election Inspector Application Form" - Walker City, Michigan

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ELECTION INSPECTOR APPLICATION
WALKER CITY
(Must be completed in your own handwriting in ink)
Name in Full_____________________________________Date of Birth_____\_____\ _____
Home Address___________________________________ Telephone #_________________
Length of Residence in City, Township, Village or School District _____________________
Registered in Precinct #______ Ward # ______ Social Security # ______-______- _______
Political Party Affiliation (to be eligible for appointment you MUST check one):
Republican Party
Democratic Party
Other Party
_____________
(Name the party)
Have you ever been convicted of a felony or election crime?
Yes_____ No_____
***************************************************************************
Educational Background – (include highest grade completed or degrees held) ____________
__________________________________________________________________________
Employment Background – (include current or last place of employment and type of work
performed) _________________________________________________________________
__________________________________________________________________________
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___
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.
_______________________________________________________ Date_____\_____\_____
SIGNATURE OF APPLICANT
* 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 election 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 ON THIS APPLICATION WILL DISQUALIFY THE APPLICANT
Approved by State Director of Elections
ELECTION INSPECTOR APPLICATION
WALKER CITY
(Must be completed in your own handwriting in ink)
Name in Full_____________________________________Date of Birth_____\_____\ _____
Home Address___________________________________ Telephone #_________________
Length of Residence in City, Township, Village or School District _____________________
Registered in Precinct #______ Ward # ______ Social Security # ______-______- _______
Political Party Affiliation (to be eligible for appointment you MUST check one):
Republican Party
Democratic Party
Other Party
_____________
(Name the party)
Have you ever been convicted of a felony or election crime?
Yes_____ No_____
***************************************************************************
Educational Background – (include highest grade completed or degrees held) ____________
__________________________________________________________________________
Employment Background – (include current or last place of employment and type of work
performed) _________________________________________________________________
__________________________________________________________________________
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___
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.
_______________________________________________________ Date_____\_____\_____
SIGNATURE OF APPLICANT
* 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 election 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 ON THIS APPLICATION WILL DISQUALIFY THE APPLICANT
Approved by State Director of Elections