Pollworker Application

Perry County Board of Elections

POLL WORKER APPLICATION

200 S. Jackson Street

New Lexington, Ohio  43764

Phone:      (740) 342-2134

Fax:     (740) 342-4787

 

(Please Print or Type on Form)

 

Are you a registered voter in Perry County?     YES or NO

 

Name:______________________________________DOB_________________________

 

Address:______________________________City:_____________________Zip:_______

 

Phone:__________________________E-Mail___________________________________

 

Party Affiliation:  __________Democrat     _________Republican     ______No Party

 

Have you ever worked as a Poll Worker?         YES or NO

 

If yes, When:______________________Where:__________________

 

Do you have computer experience:                  YES or NO

 

If yes, describe:_____________________________________________________________

 

Have you ever been convicted of a felony?     YES or NO

 

Do you have transportation on Election Day?    YES or NO

 

Are you able to lift up to 30 Lbs.?       YES or NO

 

Signature:_________________________________________________Date:_____________

 

 

Under penalty of perjury, I hereby swear or affirm that the above information is true and accurate. 

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 election laws, shall serve as an election officer, pursuant to Ohio Revised Code 3501.27.

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