ROV Letterhead                                                  

                     APPLICATION TO SERVE AS A POLL WORKER

To use this form to apply, you may choose “File”, “Print” from your computer to print out this file, including the response form below.

                                Please fill out this application and return it to: 

           COUNTY OF SAN BERNARDINO
          REGISTRAR OF VOTERS
           777 E RIALTO AVENUE
              SAN BERNARDINO, CA 92415-0770.

FULL NAME
RESIDENCE ADDRESS
CITY     ZIP CODE  
EMAIL     
MAILING ADDRESS             
CITY          ZIP CODE  
PHONE        DAY          EVENING 
OCCUPATION     

     
Please Answer:                           YES                   NO                
I am available to serve at the polls as a poll worker.                                               
I am registered to vote at the above address.                                                    
I have prior experience as a poll worker                                                         
Please indicate:  City _______________________________  County  ____________________  State ______   ) 
I speak the Spanish language.                                               
If you have previously served as a poll worker, please answer the following question
Which positions) have you served?                                    Clerk                 Inspector

 

                           APPLICANT’S SIGNATURE                                         DATE