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.

    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:


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

    This field is not part of the form submission.

29. Submit

* indicates a required field