This PDF 1.5 document has been generated by Microsoft® Word 2010, and has been sent on pdf-archive.com on 10/11/2010 at 22:33, from IP address 98.226.x.x.
The current document download page has been viewed 961 times.
File size: 84.86 KB (1 page).
Privacy: public file
Use separate form for each different incident
(use back of form to provide more information)
Joe Walsh for Congress Committee, Inc.
218 Barron Blvd. – Grayslake, IL 60030 – 847.752.8155
Fax: 847.307.7972
Email: nick@walshforcongress.com
Incident Report – November 2, 2010 General Election
(please email, deliver or fax no later than 2 days after you receive this)
(please print)
Person Reporting ___________________________
Residence Address __________________________
Phone: Day ____________ Evening ___________
Address of incident _________________________
Cellular: _____________ Pager: ______________
Email: ___________________________________
County: ________Township or Ward __________
Precinct #_______Time of incident _______am/pm
Did the Election Judges ALWAYS check the list of early and absentee voters before issuing a ballot? ___
If not, did they do so after somebody reminded them? ____ Explain below or on reverse side.
Describe incident ___________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Resolution of incident _______________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Offender __________________________________
Role in pollingplace _________________________
Residence Address __________________________
Day Phone ___________________
Evening Phone ________________
Offender _________________________________
Role in pollingplace _________________________
Residence Address __________________________
Day Phone ___________________
Evening Phone ________________
Voter Involved _____________________________
Residence Address __________________________
Day Phone ___________________
Evening Phone ________________
Voter Involved _____________________________
Residence Address __________________________
Day Phone ___________________
Evening Phone ________________
Voter Involved _____________________________
Residence Address __________________________
Day Phone ___________________
Evening Phone ________________
Witness ___________________________________
Residence Address __________________________
Day Phone ___________________
Evening Phone ________________
Witness ___________________________________
Residence Address __________________________
Day Phone ___________________
Evening Phone ________________
walsh incident report.pdf (PDF, 84.86 KB)
Use the permanent link to the download page to share your document on Facebook, Twitter, LinkedIn, or directly with a contact by e-Mail, Messenger, Whatsapp, Line..
Use the short link to share your document on Twitter or by text message (SMS)
Copy the following HTML code to share your document on a Website or Blog