Haywood County Election Commission
Courthouse – Lower Level
1 N. Washington Ave.
Brownsville, TN 38012
731-772-1760
Email:haywoodcounty@bellsouth.net                    Website: haywoodvotes.com

Poll Worker Application 

Name_________________________________________________________________		      
 Last			             First			            M.I.

Address______________________________________________________________				Street				                   City			        ZIP
E-Mail Address _______________________________________________________

Date of birth____/____/______   Social Security #   ___________-________-___________
           Mo/Day/Yr     
Home Phone______________  Work Phone_____________Cell Phone _______________
Political Party – Check one:  _____ Democratic   _____Republican  _____Independent
Employment Status
   	Employer or previous employer (if applicable)_____________________________

	Position or title_______________________________________

References
	List two people who have knowledge of your character or ability 

1. _______________________________________________________________________
		Name			                 Address			             Phone

2.________________________________________________________________________
		Name			                Address			             Phone

	Have you ever served as an election official? ________
	Are you able to work from 8:30 a.m. to 7:30 p.m. on Election Day? ________
	Do you have reliable transportation? ________
	Are you willing to travel outside your precinct to work? ________

I understand that if appointed as an election official, I will be required to attend a training class held by the Haywood County Election Commission and I will only be paid for training class if I also work Election Day.
I further understand that in order to work Early Voting, I must be able to work on Election Day.

Signature____________________________________________                   Date______________

For Office use only – Don’t write below this line

Voter Reg #_________ Precinct/Ward #______ Leg. District __________Party_______