________________________________________________________
Name of City, Township, Village or  School District.

* 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  ____

Have you ever been convicted of a felony or election crime?  Yes ____ No ____

Education 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  ____

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 "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