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2. First Name
3. Last Name
5. Address1
7. Address2
9. City
10. State
11. Zip
13. Phone*
14. Email
15. Date of Birth
19. Do you have reliable transportation?

    1. YES
    2. NO
20. Have you ever worked at a polling precinct

    1. YES
    2. NO
22. Are you willing to work outside your own precinct?

    1. YES
    2. NO
23. Are you able to work from 6:00 am to 8:00 pm on Election Day?

    1. YES
    2. NO
25. Have you ever been convicted of a felony?

    1. YES
    2. NO
26. I consider myself to be

    1. Republican
    2. Democrat
    3. Other
28. I, the undersigned, understand that if hired as a poll manager, receiving manager, bailiff or any other position at the polling precinct, I will be required to attend training classes held by the Desoto County Election Commission and/or the Mississippi Secretary of State.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

30. Electronic Signature*

    1. I agree
31. Electronic Signature*
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field