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r <br />„ 1 <br />City of Little Canada <br />Precinct <br />Minnesota Registered <br />APPLICATION FOR JUDGE OR CLERK y <br />OF ELECTION <br />Name? Mrs. <br />40as4 Firms" Middle Age? <br />Las t <br />Address? Zip/ <br />Code? -i //� Telephone?_ 7L.q . 3 % U <br />�� Social <br />If -married, what was your maiden name? 0,1�� �:� security No./% - — <br />-31e,1 04: <br />When were you born? �2 16 <br />Month Day Year <br />Are you an employee of the U.S. Government, <br />village government? Yes No 0. <br />WHAT IS YOUR PARTY AFFILIATION? <br />(Answer to above required by State Law) <br />or of 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 L� <br />If so, give details <br />Have you any disease, infirmity, or deformity? Yes v No <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 L/No <br />If so, give details ����� �✓%�,Z��' <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 />�lication Receive /— 7% <br />By <br />proved <br />SIGN HERE �/%l'� <br />CLERK'S EXHIBIT NO <br />MEETING-11-9-77 <br />1287 <br />