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2. Online Election Night or Central Count Worker Application For The 2023 General Election
4. Please note any question with a red * requires an answer. You will find that almost every question will require an answer. You will not be able to submit this form until all fields with the red * are completed.
6. Contact Information
8. First Name*
   Please use your legal name
9. Last Name*
   Please use your legal name
11. Street Address*
    Please provide the street address where you legally reside
13. City*
14. State*
15. Zip*
17. Home Phone Number*
18. Cell Phone Number*
19. Email Address*
21. What Is The Best Way To Contact You?*

    1. At The Email Address Above
    2. At The Home Number Listed Above
    3. At The Cell Phone Number Listed Above
22. What Is The Best Time To Contact You At That Phone Number?

    1. Weekday Mornings
    2. Week Day Afternoons
    3. Anytime
24. Election Night/Central Count Worker Qualifying Information
26. Are You An Adult or Student?*

    1. I Am An Adult Age 18 or Older
    2. I Am A Student Age 16 or 17
27. Are You A US Citizen?*

    1. Yes
    2. No
29. Do You Live In Porter County*

    1. Yes
    2. No
30. Are You Registered To Vote?*

    1. Yes
    2. No
32. Are you the treasurer or chairman of the committee for a candidate on the ballot?*

    1. Yes

    1. No
34. Are a you a candidate on the ballot, or a relative by birth, marriage or adoption of a candidate on the ballot?*

    1. Yes

    1. No
36. What Is Your Date Of Birth?*
    What Is Your Date Of Birth?
37. What Is Your Political Party Affiliation?*

    1. Democrat
    2. Republican
39. Poll Worker Experience
41. Which Position Are You Interested In Working?*

    1. Election Night Worker: 5:00 PM to 9:00 PM On Election Day
    2. Central Count Worker: 6:45 AM to 6:45 PM On Election Day
42. Have You Served As An Election Night Or Central Count Worker Before?*

    1. Yes
    2. No
44. Disclosures
46. This online form is ONLY an application to become an Election Night or Central Count Poll Worker. Your approval to work is not guaranteed until you receive a confirmation from the Elections & Registration Office*

    1. I Understand & Agree
48. You are almost done! Please click on "Submit" below and you will be directed to a Form Submission Confirmation Page. If you are not directed to the Form Submission Confirmation Page, then you have probably missed providing required information on this form. Please scroll up to see any highlighted fields where an answer is required, then click on "Submit" again.
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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field