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2. First Name*
3. Last Name*
5. Preferred Name
7. Date of Birth*
   Date of Birth
8. Last 4 of Social Security #*
12. Mailing Address*
14. City*
15. State*
16. Zip Code*
18. Residential Address (If different from above)
20. City
21. State
22. Zip Code
24. Email Address*
26. Phone Number*
27. Phone*

    1. Home Phone

    1. Cell Phone
31. Are you employed?*

    1. Yes

    1. No
32. If yes,

    1. Full-Time

    1. Part-Time
34. Are you able to get the necessary time off?

    1. Yes

    1. No
38. Are you a registered voter in Camden County?*

    1. Yes

    1. No
40. Have you ever been a poll worker?*

    1. Yes

    1. No
41. If yes, where?
43. Are you able to work at any precinct in the county?*

    1. Yes

    1. No
44. Which precinct(s) have you worked at?
46. At what precinct do you vote?*
50. Do you understand you will have to work at least a 14-hour day, on a Tuesday?*

    1. Yes

    1. No
52. What Election positions are you interested in working?
54. Election Day Worker (Tuesday)

    1. Clerk

    1. Co-Manager

    1. Manager
56. Advance Voting Worker (Monday-Friday)

    1. Yes

    1. No
57. Early Voting Worker (Saturday)

    1. Yes

    1. No
61. By typing your name below and submitting this online form 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. I am a United States citizen.”
63. Name*
64. Today's Date*
    Today's Date
68. Please note that contact information provided to a government agency may be subject to public release as required by Georgia’s Open Records Law.
70. Printable Version of Poll Worker Application
    Official Poll Worker Application (PDF)
71. Direct Deposit Form
    Direct Deposit Form (PDF)
73. Employee's Withholding Certificate Form W-4
    Employee's Withholding Certificate Form W-4 (PDF)
74. State of Georgia Form G-4
    State of Georgia Form G-4 (PDF)
76. Form I-9 Instructions
    Form I-9 Instructions (PDF)
77. Form I-9
    Form I-9 (PDF)
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit Submit and Print

* indicates a required field