Election Worker Application Form

First Name

Last Name

Preferred Name

Date of Birth

Home Phone Number

Cell Phone Number

Your Email Address

Street Address

City

State

Zip

I am currently registered to vote in Clay County

Yes No

I am a State of Florida retiree

Yes No

If yes, date of retirement

I understand training is required before each class.

Yes No

I have reviewed and am able to meet the requirements listed on the Election Worker Information Page .

Yes No

Additional Comments

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