First Name: *	Middle Name:	Last Name: *

Residence Address: *
City: *		State: *		Zip: *
					Invalid ZipCode
Mailing Address (if different than above):
City:		State:		Zip:
					Invalid ZipCode

Home Phone: *

Cell/Alternate Phone:

Email Address: * *

What languages do you speak?

English Spanish Tagalog Other

I’m interested in being an electronic roster clerk

Have you ever served as a poll worker before? *

Yes No

I prefer to work in (check all that apply):

Fairfield Suisun Rio Vista Vacaville Dixon Vallejo Benicia

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