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Poll Worker Application Form
Fields marked with a
*Red Asterisk*
are required.
Last Name
First Name
Middle
Address
City
Zip
Are you a seasonal resident (snowbird)?
Are you a seasonal resident (snowbird)?
yes
no
If yes, when are you here?
Phone: (Home)
Phone: (Cell)
Email Address
Date of Birth
This office uses email as the primary means of communicating with our poll workers. Therefore, access to a computer and your own personal (not shared) email address is a requirement to be a poll worker.
Are you registered to vote in Charlotte County
Are you registered to vote in Charlotte County
yes
no
If yes, Voter Registration #
Have you previously been a poll worker?
Have you previously been a poll worker?
yes
no
If yes, where?
Position held?
Are you a retiree from any State of Florida administered retirement system in the last year?
Are you a retiree from any State of Florida administered retirement system in the last year?
yes
no
Are you fluent in a language other than English?
Are you fluent in a language other than English?
yes
no
If yes, what language?
How did you hear about becoming a Poll Worker?
I HEREBY AFFIRM:
Smoking is not permitted inside any polling location and restrictions may apply outside at some locations. Is this a problem for you?
Smoking is not permitted inside any polling location and restrictions may apply outside at some locations. Is this a problem for you?
yes
no
- I am available to work 6 am to (approximately) 8 pm on Election Day;
- I am available to work 6 am to (approximately) 8 pm on Election Day;
yes
no
- I am available to work all elections in an election cycle;
- I am available to work all elections in an election cycle;
yes
no
- I will attend and complete all required training prior to each election;
- I will attend and complete all required training prior to each election;
yes
no
- I understand that if I am a substitute and do not answer my phone or are unable to work on election day morning I will forfeit any monies due me for training and/or substitute status;
- I understand that if I am a substitute and do not answer my phone or are unable to work on election day morning I will forfeit any monies due me for training and/or substitute status;
yes
no
- I am not a convicted felon OR if I was I have had my rights restored;
- I am not a convicted felon OR if I was I have had my rights restored;
yes
no
- I am able to lift approximately 42 lbs;
- I am able to lift approximately 42 lbs;
yes
no
- If I am assigned a position but I am unable to fulfill that assignment at any given time, I understand that I forfeit that position and will be placed in a substitute/alternate status until such a time as a position may become available to me;
- If I am assigned a position but I am unable to fulfill that assignment at any given time, I understand that I forfeit that position and will be placed in a substitute/alternate status until such a time as a position may become available to me;
yes
no
- I understand, as a Poll Worker, I will serve at the will of the Supervisor of Elections and may be removed at any time, with or without cause;
- I understand, as a Poll Worker, I will serve at the will of the Supervisor of Elections and may be removed at any time, with or without cause;
yes
no
- I will provide prompt responses to ALL emails.
- I will provide prompt responses to ALL emails.
yes
no
FAILURE OF A BACKGROUND CHECK OR TO COMPLY WITH ANY OF THESE AFFIRMATIONS IS GROUNDS FOR PERMANENT INELIGIBILITY TO SERVE AS A POLL WORKER IN CHARLOTTE COUNTY FLORIDA
FAILURE OF A BACKGROUND CHECK OR TO COMPLY WITH ANY OF THESE AFFIRMATIONS IS GROUNDS FOR PERMANENT INELIGIBILITY TO SERVE AS A POLL WORKER IN CHARLOTTE COUNTY FLORIDA
SUBMITTING THIS APPLICATION CONSTITUTES YOUR AGREEMENT TO COMPLY WITH ALL APPLICABLE FLORIDA ELECTION LAWS AND REGULATIONS.
SUBMITTING THIS APPLICATION CONSTITUTES YOUR AGREEMENT TO COMPLY WITH ALL APPLICABLE FLORIDA ELECTION LAWS AND REGULATIONS.
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