Election Commission

Tipton County Election Commission
Poll Worker Application

Last Name *

First Name *

Middle Initial *

Address *

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Home Phone *

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Work/Cell Phone *

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Email *

Are you currently employed? *

Name of Employer

Are you a registered voter in Tipton County? *

Political Affiliation *

Have you served as an election official? *

If so, when?

Have you been convicted of a felony? *

If yes, explain

Do you have reliable transportation? *

Can you work in early voting? *

Do you have computer experience? *

What kind?

Can you sit or stand for long periods? *

Can you lift a 22lb machine? *

Can you work from 6am to 8pm? *

Comments

Will you travel outside your precinct? *

Comments

Do you work for a government agency or an elected official? *

Comments

References: Please list two people who have knowledge of your character or ability (employer, if applicable). Please include Full Name, Address and Phone Number. *

Disclaimer and Approval: I understand that if appointed as an elected official, I will be required to attend a training class held by the Tipton County Election Commission *

I agree

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