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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 25, 2023?*

    1. Yes
    2. No
35. Are You Available to Work During The Early Voting Period From April 12-22, 2023?*

    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

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