Request For Appointment Form

2. First Name*
3. Last Name*
5. I am a registered voter in:

   1. Gloucester County
   2. Other Locality
6. Precinct You Are Registered In:
   -- Select One --HarcumSalemPeasleyCourthouseBotetourtWhite MarshRoanesHayesSarahs CreekAchilliesWalker
7. Are you willing to serve out of your precinct if needed?

   1. Yes
   2. No
9. I prefer to represent the:

   1. Democratic Party

   1. Republican Party
10. Are you willing to represent either party if needed?

    1. Yes

    1. No
12. Street Address*
14. Mailing Address (If different from above)
16. City*
17. State*
18. Zip*
20. Home Phone
21. Work Phone
22. Cell Phone
24. Email Address*
26. Thank you for applying. The strength of a democracy depends on the involvement of its citizens. Your form will be reviewed at the next electoral board meeting, which is the first Wednesday of every month.
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field