Annie D. Willams, Hernando County Supervisor of Elections
                                                    Poll Worker Application

20 North Main Street, Room 165, Brooksville, Florida 34601
Phone: (352) 754-4125  -  Fax (352) 754-4425            
Email: AWilliams@hernandocounty.us

Please complete this application  for a position as a Poll Worker.  Return this application by mail or in person to the address above. If you have any trouble with the application, please call 352-754-4125 for assistance.

Last Name: *
 

First Name: *
 

Middle Initial:
 

Voter Registration (If known): Phone Number: * Date of Birth: *

Street Address: *
 

City:
 

Zip Code:
 

Your Home Precinct:
 

Email Address:
 
PLEASE ANSWER THE FOLLOWING QUESTIONS:
YES NO
check box check box Are you a citizen of the United States and a registered voter in Hernando County?
check box check box Are you able to speak, read and write the English language?
check box check box Do you have your own transportation?
check box check box Are you able to lift 35 pounds?
check box check box Are you able to start work at 6:00 a.m. and work a 14 hour day?

Florida Statute 102.021(1) requires that you be compensated for your services as a poll worker.
However, should you so choose, you may decline payment for your services.
 

Please check one of the following:
  check box I would like to be PAID for my services as a poll worker.
  check box

I would like to VOLUNTEER my services as a poll worker.
Note: Checking the PAID box will not eliminate you from being hired as a poll worker.

 

 

Signature                                         Date

* Denotes required information