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Precinct <br />.City of Little Canada <br />Minnesota <br />Registered <br />`..� Mr. ) <br />Name? — 4esr) <br />MLXW) <br />APPL-ICATION-FOR JUDGE OR CLERK <br />OF ELECTION <br />First Middle <br />L//J <br />st <br />Age? L545 <br />AddressC. ��: Zip Code? jS-10 j Telephone?_ <br />Social <br />If -married, what was your maiden name? Security No.�'-sl�-l��-%/� <br />When were you born? - /<<� <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 N04 <br />WHAT IS YOUR PARTY AFFILIATIO ? <br />(Answer to above required by State Law) <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 <br />If so, give details <br />Have you any disease, infirmity, or deformity? Yes Nd. <br />If so, give details <br />11 <br />Have you ever consulted a physicia t any time during the past year for any <br />disease or injury? Yes No <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 />'iplication Received %C -- 12 y-% % SIGN HERE <br />By <br />Approved <br />CLERK'S EXHIBIT <br />MEETI NG-11-9-77 <br />12.31 <br />