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State of Michigan Election Inspector Application

State of Michigan Election Inspector Application (Complete in your own handwritingand return to your local City/Township Clerk - find your local Clerk at mi.gov/vote

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Text of State of Michigan Election Inspector Application

State of Michigan Election Inspector Application (Complete in your own handwriting and return to your local City/Township Clerk - find your local Clerk at ) personal information Full Name ________________________________________ ____________________________________ Date of Birth ________/________/_______ Email Address _____________________________________ Home Address ________________________________________ ________________________________ Phone # s Home: _____________________ Work: ____________________ Cell: ___________________ Registered in City or Township of _________________________ Pct # _______ Ward # ________ County of ________________________________________ ___ Political Party Affiliation (REQUIRED; must be a recognized state party & may not be Independent): Republican Democratic Libertarian Taxpayers Green Natural Law Working Class Have you ever been convicted of a felony or election crime? Yes No education and experience information Education Background (include highest grade completed or degree held) ____________________________ ________________________________________ ________________________________________ _________ Employment Background (include current or last place of employment and type or work performed) ________________________________________ ________________________________________ _________ ________________________________________ ________________________________________ _________ Languages other than English that you speak (if any) ________________________________________ ______ Please rate your computer experience (data look-up, database processing, creating .pdfs, etc.): 1 = not experienced, 5 = very experienced 1 2 3 4 5 Past experience as an election inspector, if any (include name of jurisdiction) __________________________ ________________________________________ ________________________________________ _________ Do you have transportation? Yes No Will you work at any polling place? Yes No If not, explain: _________________________________ ________________________________________ ________________________________________ _________ 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. ________________________________________ ________ ________/________/________ Signature of Applicant Date * 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 inspector. 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 MADE ON THIS APPLICATION WILL DISQUALIFY THE APPLICANT. Approved by State Director of Elections (August 2017)

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