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2. Request for additional information to be an Officer of Election
4. Name*
6. Street Address*
8. City:*
9. State:*
10. Zip*
12. Telephone Number:
14. Are you a registered voter in the City of Danville?*

    1. Yes
    2. No
Leave This Blank:


16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field