Election Polling Agent Form

Election Polling Agent Form
Register as a polling agent for election duty. Please provide accurate details for assignment and communication.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Residential Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Polling Location
Role Preference
Other
Preferred Shift
Do you have previous polling agent experience?
Agent Reference ID (if assigned)
Should be Empty: