_ __ __ __ __ __ __ __ __ _

M Me er rc ce er r C Co ou un nt ty y B Bo oa ar rd d o of f E El le ec ct ti io on ns s
D Di is st tr ri ic ct t B Bo oa ar rd dw wo or rk ke er r A Ap pp po oi in nt tm me en nt t A Ap pp pl li ic ca at ti io on n f fo or r 2 20 01 14 4

J Jo oa an nn ne e P Pa al lm mu uc cc ci i, , C Ch ha ai ir rw wo om ma an n A An nt th ho on ny y R R. . F Fr ra an nc ci io os so o, , E Es sq q. . , , S Se ec cr re et ta ar ry y
P Pe et te er r D D. . N Ni ic ch ho ol ls s, , M Me em mb be er r A An nt th ho on ny y J J. . C Co on nt ti i, , M Me em mb be er r


B Bo oa ar rd dw wo or rk ke er r e el li ig gi ib bi il li it ty y i in nc cl lu ud de es s: :
Y Yo ou u m mu us st t b be e a at t l le ea as st t 1 18 8 y ye ea ar rs s o ol ld d, , h ha av ve e y yo ou ur r o ow wn n t tr ra an ns sp po or rt ta at ti io on n a an nd d b be e r re eg gi is st te er re ed d t to o v vo ot te e i in n M Me er rc ce er r C Co ou un nt ty y. .
A Al ll l B Bo oa ar rd dw wo or rk ke er rs s a ar re e e en nc co ou ur ra ag ge ed d t to o v vo ot te e b by y M Ma ai il l- -I In n B Ba al ll lo ot t. .

F Fi ir rs st t N Na am me e M Mi id dd dl le e I In ni it ti ia al l L La as st t N Na am me e D Da at te e o of f B Bi ir rt th h

A Ad dd dr re es ss s A Ap pt t/ /U Un ni it t C Ci it ty y S St ta at te e Z Zi ip p
( ( ) ) ( ( ) ) ( ( ) )
H Ho om me e T Te el le ep ph ho on ne e C Ce el ll l N Nu um mb be er r W Wo or rk k N Nu um mb be er r

A Ad dd dr re es ss s y yo ou u a ar re e r re eg gi is st te er re ed d a at t i if f d di if ff fe er re en nt t f fr ro om m a ab bo ov ve e
P Pa ar rt ty y R Re eg gi is st tr ra at ti io on n: :
E E- -m ma ai il l a ad dd dr re es ss s
I I A Am m A Av va ai il la ab bl le e T To o W Wo or rk k: :

S Su up pp po or rt ti iv ve e S Se er rv vi ic ce e Q Qu ue es st ti io on ns s: :
A Ar re e y yo ou u a ab bl le e t to o p pi ic ck k- -u up p t th he e s su up pp pl ly y b ba ag g f fr ro om m t th he e m mu un ni ic ci ip pa al l c cl le er rk k? ? Y Ye es s N No o
A Ar re e y yo ou u a ab bl le e t to o r re et tu ur rn n t th he e s su up pp pl ly y b ba ag g t to o t th he e m mu un ni ic ci ip pa al l c cl le er rk k? ? Y Ye es s N No o
H Ha av ve e y yo ou u p pr re ev vi io ou us sl ly y s se er rv ve ed d a as s a an n e el le ec ct ti io on n b bo oa ar rd d w wo or rk ke er r i in n M Me er rc ce er r C Co ou un nt ty y? ? Y Ye es s N No o
A Ar re e y yo ou u B Bi il li in ng gu ua al l? ? L La an ng gu ua ag ge e: : Y Ye es s N No o



Applicant must read before signing: This application, signed by the applicant under his or her oath, shall state: (1) the applicant's name and
address; (2) the applicant's age, if the applicant is less than 18 years of age; (3) the political party to which he or she belongs or, if the applicant
is not affiliated with a political party, the fact that the applicant is not so affiliated; (4) that the applicant is of good moral character and has not
been convicted of any crime involving moral turpitude; and (5) that the applicant possesses the following qualifications: eyesight, with or without
correction, sufficient to read nonpareil type; ability to read the English language readily; ability to add and subtract figures correctly; ability to
write legibly with reasonable facility; reasonable knowledge of the duties to be performed by the applicant as an election officer under the
election laws of this State; and health sufficient to discharge his or her duties as an election officer. N.J.S.A 19:6-2b I certify that the
above answers and information are true and that this application and signature are in my own handwriting.


Applicant Signature Date
Sworn to and subscribed before me on
this _________ day of ____________________ (If you are currently a Boardworker, you do not
need to have this application notarized.)
_____________________________________
Notary Public of New Jersey

6 64 40 0 S So ou ut th h B Br ro oa ad d S St tr re ee et t, , P PO O B Bo ox x 8 80 06 68 8
T Tr re en nt to on n, , N NJ J 0 08 86 65 50 0- -0 00 06 68 8
B Bo oa ar rd do of fE El le ec ct ti io on ns s@ @M Me er rc ce er rc co ou un nt ty y. .o or rg g
( (6 60 09 9) ) 9 98 89 9- -6 65 52 22 2
If Half Day Shift:
General Election, November 4, 2014 Yes ____ No ____ a.m. ____ p.m. ____
Will you work in another municipality? Yes ____ No ____
Half Day shifts are either a.m. (5:15 a.m. to 1:00 p.m.) or p.m. (1:00 p.m. to 8:30 p.m.)
All assignments are at the discretion of the Board of Elections.