V:/TECH/VRFILE/DISKS/DiskFormCheckFillable.doc REV 11/11
Robin M. O'Connor
Lake County Clerk
18 North County Street, Room 101
Waukegan, Illinois 60085-4364
LakeCountyClerk.info
Phone 847 377 2400
Fax 847 984 5827
OFFICE USE ONLY
Date Application Received: ______________ Hard-Disk Space Needed: ______________
Campaign Disclosure OK: ______________ Data Current as of: ______________
Number of Voter Records: ______________ Total Cost: ______________
Prepared by: ______________
File Name: ____________________________________________________________________________
Contact Person:
Street Address:
City:
Zip:
Telephone: Fax: Email:
Political Committee:
District(s) Requested: ____________________________________________________________________
Information will be provided on compact disk (CD). Voter history will be given for the last five (5) elections
unless specific elections are specified.
Data Format:
ASCII Delimited (text) Voter History Dates (check no more than 5 boxes)
Microsoft Access Database Year ______
Primary Gen/Consol.
Microsoft Excel 2007 Spreadsheet Year ______
Primary Gen/Consol.
Other _____________________ Year ______
Primary Gen/Consol.
Year ______
Primary Gen/Consol.
Year ______
Primary Gen/Consol.
Delivery Instructions:
Hold for pick up (Name)
Mail (address, if different from above)
(pre-payment required)
I, the undersigned, receive this data with the understanding and agreement that only a bona fide political committee registered
pursuant to the Illinois Campaign Finance Act or the Federal Campaign Act, or, in the alternative, a governmental entity
qualified under state law using the data for a governmental purpose and not in violation of any state laws or applicable ethics
ordinances, may receive this data. Payment for voter registration data must be made with campaign committee funds as
either a campaign committee check or money order or with a government entity check. I further acknowledge this data
will be used only for bona fide (political and governmental informational) purposes and shall not be used under any
circumstances for purposes of commercial solicitation or other business purposes and that, to do so, may result in substantial
penalty. (10 ILCS 5/4-8, 5-7 and 6-35)
Signature of Applicant:
Date:
APPLICATION FOR VOTER COMPACT DISK
