State of Michigan Election Inspector Application

2. State of Michigan Election Inspector Application

4. Personal Information

6. First Name*

7. Last Name*

9. Date of Birth*

11. Address

13. City

14. State

15. Zip Code

17. Phone Number

18. Fax Number

20. Email Address

22. Registered in

    1. City
    2. Township

23. City or Township Name

24. Pct #

25. Ward #

27. County of

29. Political Party Affiliation (must be a recognized state party & may not be independent)

    1. Republican
    2. Democratic

    1. Libertarian
    2. U.S. Taxpayers

    1. Green
    2. Natural Law

31. Have you ever been convicted of a felony or election crime?

    1. Yes

    1. No

33. Education and Experience Informaion

35. Education Background (include highest grade completed or degree held)

37. Employment Background (include current or last place of employment and type of work performed)

39. Languages other than English that you speak (if any)

41. Please rate your computer experience (data Look-up, database processing, creating pdfs, etc.): 1 = not experienced, 5 = very experienced

    1. 1
    2. 2

    1. 3
    2. 4

    1. 5

43. Past experience as an election inspector, if any (include name and jurisdiction):

45. Do you have transportation?

    1. Yes

    1. No

47. Will you work at any polling place?

    1. Yes

    1. No

48. If not, explain:

50. Signature and Certification
    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.

    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.

52. Signature of Applicant*

53. Date
    Date

55. * 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 peron will serve as an inspector. "Documented public statements" means statements reported by the news media or written statements with a clear and unambiguous attribution to the applicant.

57. Do you Agree?*

    1. I Agree

    By clicking "I agree", you agree and acknowledge that 1) your application will not be "signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.

59. ANY FALSE STATEMENTS MADE ON THIS APPLICATION WILL DISQUALIFY THE APPLICANT

61. Approved by State Director of Elections (June 2015)

Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field