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2. 
3. Election Inspector Application

   City Clerk Jennifer A. Zelmanski

   (586) 445-5443

5. APPLICANT INFORMATION
7. Full Name*
9. Date of Birth*
10. Email Address*
12. Home Address*
14. Home City*
15. Home State*
16. Home Zip Code*
18. Length of Residence in Macomb County*
19. Currently Registered in*
21. Business Phone Number*
22. Owner Contact Phone Number*
24. Are you interested in becoming a Chair/Co-Chair?*

    1. Yes
    2. No
25. Have you ever been convicted of a felony or election crime?*

    1. Yes
    2. No
26. Political Party Affiliation*

    1. Republican Party
    2. Democratic Party
    3. Libertarian
    4. U.S. Taxpayer

    1. Natural Law
    2. Green Party
    3. Working Class

    Must be a recognized party in the State of Michigan & may NOT be Independent.

28. Please rate your experience with Technology.*

    Looking up data, database processing

    1= Not Experienced   5=Very Experienced

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
29. Do you have transportation?*

    1. Yes
    2. No
30. Are you available to work any polling location?*

    1. Yes
    2. No
32. Home Phone Number*
33. Availability for 2024 Elections:*

    Please check all that apply.

    1. February 27, 2024
    2. August 6, 2024
    3. November 5, 2024
35. Mobile Phone Number*
37. Emergency Contact*
39. Educational Background*
41. Employment History*
43. Past Experience as an Election Worker*
47. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    I further certify that I am not a member or a known active advocate* of a political party other than the party identified above.  The foregoing statements are true to the best of my knowledge and belief.

    * A "Known active advocate" of another political party is defined to mean a person who 1) is a delegate to the convention or an officer of another party; 2) is affiliated with another party through an elected or appointed government position; or, 3) has made documented public statements specifically supporting by name another political party or its candidates in the same calendar year as the election at which the person will serve as an election inspector.  "Documented public statements" means statements reported by the news media or written statements with a clear and unambiguous attribution to the applicant.

    APPROVED BY THE STATE DIRECTOR OF ELECTIONS

    1. I agree.
49. Electronic Signature*
51. Date*
53. Non-Electronic Submittal Instructions

    If you choose to print this application, please mail or hand deliver it to:

     City Clerk's Office

     c/o Jennifer A. Zelmanski, City Clerk for the City of Roseville- 29777 Gratiot Avenue, Roseville, MI  48066.

    Any False Statements made on this application will disqualify the applicant.

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

* indicates a required field