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_Precinct <br />Mr. ) <br />Name? rs ) <br />Miss) <br />h <br />City of Little Canada <br />Minnesota <br />APPLICATION FOR JUDGE OR CLERK <br />OF ELECTION <br />First Middle <br />Last <br />0 <br />.Registered <br />Age? <br />Address? ��l% ��,4��., Zip Code? // 7 Telephone? �� f <br />Social <br />If -married, what was your maiden name? �;, Security No. <br />When were you born? <br />Month Day Year <br />Are you an employee of the U.S. Government, or of <br />village government? Yes Q No <br />WHAT IS YOUR PARTY AFFILIATION? <br />(Answer to above required by State Law) <br />any state, county, city or <br />DEMOCRATIC FARMER -LABOR <br />REPUBLICAN <br />_ AMERICAN <br />OTHER <br />Have you ever been found guilty by any court of any violation of the law? Yes _ No k <br />,ftope If so, give details <br />Have you any disease, infirmity, or deformity? Yes No 4 <br />If so, give details <br />Have you ever consulted a physician at any time during the past year for any <br />disease or injury? Yes No I <br />If so, give details <br />ANY FALSE STATEMENT ON THIS APPLICATION IS PUNISHABLE BY LAW <br />I certify that the statements made by me in this application are true, complete, <br />and correct to the best of my knowledge, and are made in good faith. <br />plication Received��- <br />By <br />proved , '- ,7c —77_ 4:��e <br />./' f <br />SIGN HERE -'1 ? • /�--�- -c J <br />CLERK'S EXHIBIT NO. <br />MEETING-11-9-77 <br />