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City of Little Canada Registered <br />Minnesota <br />Precinct yr <br />r <br />APPLICATION FOR JUDGE OR CLERK <br />OF ELECTION <br />i__) s"/sA <br />V A)1',n tit <br />A$ <br />Name? <br />Miss) First <br />Middle <br />Last <br />. <br />Address? 317 -5'-A JA6 , <br />-Z^J Zip Code? S 3%/ 7 Telephone? <br />- �•• <br />If married, what was your maiden name? �/�� �.�. . <br />Social <br />VA uk *r �J Security No. <br />3 - �� 7 7 D <br />When were you born? <br />Month <br />Day Year <br />Are you an employee of the U.S. Government, or of any state, county, city or <br />eyT <br />village government? Yes Q No <br />WHAT IS YOUR PARTY AFFILIATION? ENIOCRATIC FARMER -LABOR <br />(Answer to above required by State Law) <br />REPUBLICAN <br />AMERICAN <br />OTHER <br />Have you ever been found guilty by any court of any violation of the law? Yes _ No Z <br />�If so, give details <br />Have you any disease, infirmity, or deformity? Yes No k/0' <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 />A4 <br />SIGN HERE <br />Received / , — �% <br />�licati�i - <br />By 1/'-- /151,CC•� <br />roved % <br />fT <br />CLERK'S EXHIBIT NO. <br />MEETING-11-9-77 <br />