Poll Watcher Credentialing Form

Applicant Information

First Name:

Last Name:

Date of Birth:

SSN - Last 4 Digits Only:

Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Height in Feet:

Height in Inches:

Weight (Lbs):

Hair Color:

Eye Color:

Driver's License / State ID Number:

Email Address:

Emergency Contact Information

First Name:

Last Name:

Relationship:

Phone number:

Address:

City:

State:

Zip Code:

Are you pollwatching as a candidate, on behalf of a candidate, or on behalf of a political party, a qualified organization of citizens or proponents/opponents of a ballot proposition or nonpartisan civic organization?

Criminal / Civil History

Have you ever been arrested?

Enter date of arrest:

Do you have a criminal case pending against you?

Enter date of case:

Do you have a family member / friend in Sheriff's office custody?

Location of family member:

Have you ever been convicted of a misdemeanor or felony?

Enter date of conviction:

Do you have a civil case pending against you?

Enter date of civil case:

Have you ever visited an Individual in Custody?

Date of visit: