ELECT-633 EPB L&A Testing Certification

Before You Start

This survey replaces the paper version of ELECT-633/SBE-633. Please do not mail, fax, or email these forms to the Department as they will not be accepted.

The survey cannot be saved; once you start, if you time out or close before submitting, you will have to start over.

General Information

Date of Election * +

Use the calendar icon to find the election date

for which you are completing this survey.

<--- Click on the election date to enter it in the field.

Locality *

Locality Representative

First Name *

Last Name *

Position *

Electoral Board Member

General Registrar

Other: Other:

Email Address *

Confirm email address *

Certification

My locality will NOT use EPBs for (check all that apply):

Early Voting/AB

Election Day

This L&A testing certification applies to EPBs: *

Only Early Voting/AB EPBs

Only Election Day EPBs

Both Early Voting/AB and Election Day EPBs

I, the undersigned, certify to the Department of Elections that:

I personally witnessed the final testing of the electronic poll books for Early Voting/AB and/or the final testing of electronic poll books for election day by precinct as indicated above;
The equipment was properly set up with the correct voter files this election; and
The testing and set up was conducted as required by Va. Code §§ 24.2-632 and 24.2-633.

*

Yes

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Signature *

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Today's date * +

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