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I am interested in being a...
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Inspector (and/or)
Clerk
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I can provide a polling place
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Business
Residence
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Are you a registered voter in L.A. County?
OR (please answer both)
Are you a legal permanent resident?
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Yes
No
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Yes
No
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First Name * (Legal or as Registered)
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Last Name * (Legal or as Registered)
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Middle Initial
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Date Of Birth
*
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mm/dd/yyyy
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Address * (Legal or as Registered)
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Apartment
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City *
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Zip Code *
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Daytime Phone Number *
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e.g. 111-222-3333
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Cell Phone Number
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Email Address
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If you speak a second language, please select one
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Have you been a poll worker before?
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Yes
No
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