Registration Form

Registration Form

POLLWORKER & POLLING PLACE ONLINE APPLICATION
I am interested in being a...	Inspector Clerk Interpreter
I can provide a polling place	Business Residence
Are you a registered voter in L.A. County?	Yes No
First Name * (As Registered)
Last Name * (As Registered)
Middle Initial
Date Of Birth *	mm/dd/yyyy
Address * (As Registered)
Apartment
City *
Zip Code *
Daytime Phone Number *	e.g. 111-222-3333
Cell Phone Number
Email Address
If you speak a second language, please select one
Have you been a pollworker before?	Yes No

* indicates a required field Questions? Call (866) 899-VOTE (8683)