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2. Chesterfield Township Election Inspector Application
4. Personal Information
6. First Name*
7. Middle Name
8. Last Name*
10. Phone Number*
11. Cell Phone Number
13. Home Address*
14. City/Zip Code*
15. Email Address*
17. Emergency Contact Information
19. Name*
20. Phone Number*
21. Secondary Phone Number
23. Name*
24. Phone Number*
25. Secondary Phone Number
27. Political Party Affiliation
29. To be eligible, you MUST choose one political party*

    1. Republican
    2. Democratic

    1. US Taxpayers
    2. Libertarian

    1. Green
    2. Natural Law

    1. Working Class
31. Are you a registered voter?*

    1. Yes
    2. No
32. If yes, where are you registered to vote?
34. General Employment Questionnaire
36. Have you ever been convicted of a felony or an election crime?*

    1. Yes
    2. No
37. If yes, please explain:
39. Do you have reliable transportation?*

    1. Yes
    2. No
40. Are you willing to work at any polling location?*

    1. Yes
    2. No
41. Please rate your level of computer experience (data look up, processing, pdfs, etc.)*
    -- Select One --1 - No experience2 - Limited experience3 - Average experience4 - Above average experience5 - Highly experienced
43. Educational & Employment History
45. Educational Background (Include highest grade completed or degree(s) held)*
47. Employment Background (Include current or last place of employment and type of work performed)*
49. Do you have previous experience as an election inspector?*

    1. Yes
    2. No
50. If yes, please name the jurisdiction
52. Certification & Signature
54. 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 person will serve as an election inspector. “Documented public statements” means statements reported by the news media or written statement with a clear and unambiguous attribution to the applicant.
56. 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.*

    1. Yes, I agree

    1. No, I do not agree
58. By checking the box, I agree and certify that my printed signature is my signature and I agree to conduct this transaction electronically.*

    1. I agree.
60. E-Signature*
    Type Legal Name
61. Date*
    Date of Signature
63. ANY FALSE STATEMENTS ON THIS APPLICATION WILL DISQUALIFY THE APPLICANT
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field