Poll Worker Registration

2. First Name*

3. Last Name*

4. Suffix

6. SSN*

   (For Finance Purposes)

7. Date of Birth*
   Date of Birth

9. Address*

   Enter your physical address. Please do not enter a PO Box.

11. City*

12. State*

13. Zip Code*

15. Phone Number*

16. Email Address*

18. Currently Employed? If so, where?*

20. Occupation*

21. Work Phone*

23. Are You a United States Citizen?*

    1. Yes
    2. No

25. Do You Live in Monongalia County?*

    1. Yes
    2. No

27. Are You a Registered Voter?*

    1. Yes
    2. No

29. Have You Ever Served as a Poll Worker?*

    1. Yes
    2. No

31. Where / When?*

33. Are You Available to Work on Election Day, April 27, 2021?*

    1. Yes
    2. No

35. Are You Available to Work During The Early Voting Period From April 14 - 24, 2021?*

    1. Yes
    2. No

37. Are You Comfortable Using Desktop and Mobile Technology?*

    1. Yes
    2. No

39. Do You Speak a Language Other than English?*

    1. Yes
    2. No

41. If So, What Language?*

43. Do You Have Transportation?*

    1. Yes
    2. No

44. Are You Available to Attend the Mandatory Training?*

    1. Yes
    2. No

46. What Is Your Political Affiliation?*
    -- Select One --DemocraticRepublicanLibertarianMountainIndependent

48. Are You Available to Begin Work at 5:30 a.m. and Work 14+ Hours, if Necessary, on Election Day?*

    1. Yes
    2. No

50. Comments/Questions?

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field