Poll Worker Application

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Name(Required)

First Middle Initial Last

Physical Address(Required)

Street Address City State ZIP Code

Mailing Address(Required)

Street Address or PO Box City State ZIP Code

Email Address(Required)

Home Phone(Required)

Cell Phone

Work Phone

Party Preference or Affiliation

Democrat

Republican

Independent

**Pursuant to A.C.A § 7-4-107, the Election Commission will appoint workers in accordance with party affiliation. **

Emergency Contact(Required)

First Name Last Name

Relationship(Required)

Phone Number(Required)

In order to be paid for working at the polls, new workers must submit a photocopy of your social security card and complete a W-4 Form.

Must be a qualified elector of this state
Must be able to read and write the English language
Must be a resident of the precinct in which he or she serves at the time of his or her appointment, unless the county board determines unanimously that it is impossible to obtain qualified election officials from the precinct, in which case, the election official may be qualified county residents
Must not have been found guilty or pled guilty or nolo contendere to the violation of any election law of this state
Must not be paid employees of any political party
Must not be paid employees of any person running for office
Must not be a candidate for any office to be filled at an election while serving as an election official
Must not be married to or related within the second degree of consanguinity to any candidate running for office in the current election if objection to the service is made to the county board of election commissioners within ten calendar days after posting the list of election officials

Signature and Certification of Information(Required)

I hereby certify that I have read and I understand the qualifications for poll workers according to A.C.A §7-4-109.

Phone

This field is for validation purposes and should be left unchanged.