Washington State Republican Party

Voter Vault Local Access Request

County: _______________________________________________________________________
Chairperson: ___________________________________________________________________

Information on individual for whom access is being requested:

Name: ________________________________________________________________________
Street Address: _________________________________________________________________
City/ZIP: ______________________________________________________________________
Home Phone:___________________________ Work Phone: ____________________________
Email: ________________________________________________________________________
Is this individual a PCO? _______ If yes, for which precinct? ____________________________
I am requesting access for this individual for the Voter Vault encompassing: (choose one)
__________ County

__________ Legislative Dist.

__________ Precinct

I, __________________________, chair of the ________________________ County

Republican Party, attest that the information provided above is true; that I understand WSRP
reserves the right to deny or retract Voter Vault access to these and any individuals without
notice; and, that it is my responsibility to ensure the security of the Voter Vault and prevent its
abuse by the individual for whom I have requested access.
Respectfully submitted,
APPROVED BY:
_____________________________
Signature
Date
(County Chairman)

____________________________________
Signature
Date
(WSRP Chairman or Executive Director)

Please return this document to WSRP at:

2840 Northup Way, Suite 140, Bellevue, WA 98004
or via fax at (425) 460-0571