2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Languages Spoken (other than English)
14. Are you a registered voter of Luzerne County?*

    1. Yes, I am a registered voter of Luzerne County

    Check this box ONLY if you are a registered voter of Luzerne County.
15. Are you 18 years of age or older?*

    1. Yes, I am at least 18 years of age

    Check this box ONLY if you are at least 18 years of age?
16. I will attend a mandatory Poll Worker training session. I understand that if I do not attend training, I will not receive payment for training. *

    1. I agree to attend the Poll Worker training session

    By checking this box, you agree to attend a mandatory Poll Worker training session and understand that if you do not attend training, you will not receive compensation for training.

17. I am not a government employee*

    1. I certify that I am not a government employee.
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit Submit and Print

* indicates a required field