Poll Worker Application Form

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Please fill in the following information:

Name

Home Address

Mailing Address

City

County

Zip Code

Politics

Home Phone

Address and Phone Number if not at home during the day:

Business Name

Address

City

Zip Code

Work Phone

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Signature:_______________________________________Date:______________

Please sign and mail to:

HOLMES COUNTY BOARD OF ELECTIONS
75 E Clinton St Suite 108
Millersburg OH 44654-1249