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2. Know Your Vote
4. The purpose of this application is to obtain your voting history. Information submitted in this application will be used solely for this purpose. If you are not a resident of Chesterfield Township please contact your local Clerk.
6. First Name*
7. Last Name*
9. Date of Birth*
   Date of Birth
11. Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Email Address*
20. How would you like to receive your report?*
    -- Select One --EmailMailPick up in office
22. By checking the box, I agree and certify that my printed signature is my signature and I agree to conduct this transaction electronically.*

    1. I agree
24. E-Signature*

    Type Legal Name

25. Date*

    Date of Signature

27. Additional questions or concerns can be directed to the Clerk's Office at (586) 949-0400 opt. 5 or by email at election@chesterfieldtwp.org.
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

* indicates a required field