Registrar of Voters

501 Main Street South
(Room 106)
Southbury, CT 06488
Maps and Directions

P:(203) 262-0644
Monday - Thursday:
8:00am - 4:30pm
Friday: Closed

Poll Worker Application Form

Before completing the form, please read the information on Become a Poll Worker page.

Application/Interest Form:

CitizenshipAre you a U.S. Citizen?

Registered to VoteAre you registered to vote in Connecticut? (Must be 18 years of age.)

First Name

Last Name

Date of Birth

RESIDENTIAL ADDRESS

Residential Street

Residential City or Town

Residential Zip Code

MAILING ADDRESS (if different from residential address)

Street

City or Town

Zip Code

Email Address

Primary Phone Number

Alternate Phone Number

OccupationWhat is your current/last occupation?

Previous Poll Worker ExperienceHave you ever served as a poll worker?

Details of Previous Poll Worker ExperienceIf you answered “Yes” above, where & when did you work?

Other LanguagesAre you able to assist voters in a language other than English? If yes, please list.

DutiesPlease indicate what types of duties you would be comfortable undertaking. (Check all that apply.)

Greeting electors and line management “Checker” – verifying & cross electors off of paper street list Distributing ballots & entering electors on a computer/poll book Tabulator tender Moderating polling location (requires certification)

Standby Poll WorkerAre you willing to be a “stand-by” poll worker? As a stand-by poll worker you will be notified to report to work only if your services are needed.