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COLUMBIA COUNTY BOARD OF ELECTIONS 500 FAIRCLOTH DR. EVANS, GA 30809 (706) 868-3355 Office (706) 868-3358 Fax www.columbiacountyga.gov Email: [EMAIL REDACTED] POLL WORKER EMPLOYMENT APPLICATION APPLICANT INFORMATION Last Name First Name Middle Name Physical & Mailing Address: Apartment/Unit # City State Zip Phone/Cell: Email Address: Are you a registered voter? YES NO Date of Birth: Social Security Current or most recent employer? Are you a resident of Columbia County? YES NO Are you a citizen of the United States? YES NO Are you a Columbia County employee? YES NO Have you ever worked as a poll official? YES NO If so, where? Have you ever been convicted of a felony? YES NO Race: Gender: Male Female Do you have reliable transportation? YES NO Do you foresee any problems working at least a 14 hour day? YES NO PLEASE CHECK ANY POSITIONS YOU ARE INTERESTED IN Election Day Worker: Manager Assistant Manager Clerk Advance Voting Worker: YES NO Precinct/Polling Place DISCLAIMER AND SIGNATURE By your signature you are stating, "I am at least 16 years of age, able to read, write and speak the English language, I do not hold a public office, nor am I related to a candidate whose name will appear on the ballot and I am a United States citizen." Signature: Date: For Office Use Only: Reg. Precinct: Assigned Precinct: