OFFICE OF THE

BOARD OF ELECTIONS
County of Mercer, New Jersey
McDade Administration Building

Joanne Palmucci Chairwoman

Anthony R. Francioso, Esq. Secretary
Peter D. Nichols Board member
Anthony J. Conti Board member

P. O. Box 8068
640 South Broad Street
Trenton, New Jersey, 08650-0068
BoardofElections@mercercounty.org
(609) 989-6522 phone (609) 278-2713 fax

Permission to Serve as a Board Worker for the

Mercer County Board of Elections
(NJSA 19:6-2)

Student Information:
Name (Please print):

_________________________________________________________

Address:

_________________________________________________________

City & Zip:

_________________________________________________________

Cell Phone Number:

________________________________Date of Birth:______________

E-mail address:

_________________________________________________________

Signature of Parent or Guardian:

Name (Please print):

_________________________________________________________

Phone Number:

_________________________________________________________

I hereby approve my child assisting at a polling location in Mercer County for the 2014 Trenton
Municipal Election, June Primary Election and/or the November General Election, schedule permitting.
_________________________________________________________
(Signature of Parent or Guardian)

High School Information:

Name of School:

___________________________________________

Name of Representative (Please print):

___________________________________________

On behalf of the above named school, I excuse this student from school and give the student permission
to work as a Mercer County Election Board Worker on the below listed election dates.
_________________________________________________________
(Signature of School Representative)

Are You Available To Work:

General Election, November 4, 2014

Primary Election, June 2nd, 2015

Which shift*:

Yes ____ No ____

Yes ____ No ____

a.m. ____ p.m. ____

a.m. ____ p.m. ____

(*The a.m. shift is from 5:15 a.m. until 1:00 p.m. The p.m. shift is from 1:00 p.m. until 8:15 p.m. Half day pay is $100.00.)
(Students 16 or 17 years old may work a half day with the permission of their school and parent or guardian. Students 18 years
old and registered to vote are eligible to work a full day 5:15 a.m. until 8:15 p.m. Full day pay is $200.00.)*2009 ns are only in
Robbinsville and West Windsor Townships)

Transportation (to and from polling location) to be provided by:

Name:

___________________________________________
(Please print)

Phone number:

___________________________________________