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Precinct <br />'`,✓ Mr. ) <br />Name? Mrs. <br />KUs) /--7 First <br />H I <br />City of Little Canada <br />Minnesota <br />APPLICATION FOR JUDGE OR CLERK <br />OF ELECTION <br />Middle Last <br />.Registered <br />71 _, <br />Age? � 9 <br />Address?�-Z--. i /1 .. Zip Code? Telephone?_ <br />Social <br />If -married, what wad your maiden name? L fZZ Security No. el 77 <br />When were you born? l/ // 7 <br />Month Day Year <br />Are you an employee of the U.S. Government, or of any state, county, city or <br />village government? Yes Q No <br />WHAT IS YOUR PARTY AFFILIATION? <br />(Answer to above required by State Law) <br />X 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 X <br />If so, give details <br />Eon <br />Have you any disease, infirmity, or deformity? Yes No _2� <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 74. <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 />' -pl ication Received <br />toe BY-- <br />ADDroved <br />SIGN HERE r�� n� r •.�� �.� -� <br />CLERK'S EXHIBIT NO. 12 89 <br />MEETING-11-9-77 <br />