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2. Please fill out and submit ONLY if interested in being a worker.
4. Basic Information
6. Name*
8. Address*
   Address & City
10. Home Phone #
11. Cell Phone #*
13. Email*
15. Can you accept text messages?*

    1. YES
    2. NO
16. Would it be ok if we sent information to you via text and email?

    1. YES - it is ok to text and email
    2. NO - I prefer a phone call
18. Would you like to:*

    1. Be paid for your work at the election
    2. Volunteer your time
20. Are you registered to vote?*

    1. YES
    2. NO

    All election workers must be registered voters in Riley County.

21. What is your party affiliation?*

    1. Democrat
    2. Republican
    3. Libertarian
    4. Unaffiliated
23. History and Experience
25. 1. Have you ever worked at an election before?*

    1. YES
    2. NO
27. If yes, where?
28. What was your role?
30. 2. Do you have computer experience?*

    1. YES
    2. NO
32. 3. Are you willing to work at any polling location in Riley County?*

    1. YES
    2. NO
34. 4. Do you need any accommodations to assist in fulfilling your duties?*

    1. YES
    2. NO
36. If yes, please list any accommodations needed.
38. 5. Are you able to stand for long periods of time?*

    1. YES
    2. NO
40. 6. Have you ever been convicted of a misdameanor or felony?*

    1. YES
    2. NO
42. If yes, list when, where, and nature of offense(s).
44. 7. Do you know of anyone else who would be interested in working the elections?

    Name, Address & Phone

46. Please list a name(s) and telephone number(s) of someone that we may contact in an emergency.
48. Contact #1*
49. Phone #*
51. Contact #2
52. Phone #
54. Please Read:
    “I swear or affirm that I am a citizen of the United States and a Kansas resident, that if convicted of a felony, I have had my civil rights restored. I have told the truth on this worksheet, and the information provided is complete and correct to the best of my knowledge. I understand that any incomplete, incorrect or false information furnished by me may void this application.”
56. Electronic Signature of Applicant*
57. Date*
    Date
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit Submit and Print

* indicates a required field