CALIFORNIA APPLICATION FOR CERTIFICATION OF AN ELECTRONIC POLL BOOK SYSTEM

Part 1 of 4

REQUEST FOR ELECTRONIC POLLBOOK

CERTIFICATION & SYSTEM IDENTIFICATION

  1. APPLICATION DATE:
  2. e-POLLBOOKSYSTEM NAME AND VERSION:
  3. APPLICANT(S)-

Name:
Principal Address:
Type: Manufacturer Distributor Jurisdiction Other:
Name:
Principal Address:
Type: Manufacturer Distributor Jurisdiction Other:
  1. VENDOR CONTACT:

Name of Contact for Certification:
Title of Contact:
Mail Address:
Telephone: / Fax: / Email:
  1. IDENTIFICATION OF SYSTEM COMPONENTS:

Hardware

Name (Model #) / Version / Description

Software

Name / Version / Description

COTS Components

Name / Mdl/Version / Manufacturer or Specs; Description
  1. EXISTING CUSTOMERS – Identify all current California customers that will be affected by this certification request:

I hereby certify that the information submitted on this application, including Parts 1-4 and associated documentation is true, accurate and complete Finally, I certify that I am legally authorized to sign and submit this application on behalf of the applicant organization(s).

SignatureSignature

Name (printed)Name (printed)

OrganizationOrganization

DateDate

Part 2 OF 4

OWNERSHIP AND CONTROL

APPLICATION DATE:

e-POLL BOOK SYSTEM NAME AND VERSION:

  1. APPLICANT INFORMATION
  2. APPLICANT’S FULL LEGAL NAME:
  3. TYPE OF ENTITY:

Publicly-held corporation / Privately-held corporation / Subchapter S Corporation
LLC / Partnership / Sole Proprietorship
Other:

1.3.DATE ESTABLISHED:

1.4.PRIMARY STATE OF INCORPORATION (OR REGISTRATION):

1.5.PRINCIPAL ADDRESS:

1.6.PRINCIPAL OFFICERS AND THEIR MAILING ADDRESSES:

1.7.AGENT OF RECORD AND MAILING ADDRESS:

1.8.IDENTIFY LEGAL NAME AND ADDRESS OF ALL ENTITIES WITH MORE THAN 10% OWNERSHIP INTEREST IN ENTITY:

1.9.D-U-N-S® NUMBER:

1.10.GROSS ANNUAL SALES FOR THE LAST THREE FISCAL YEARS:

  1. MANUFACTURING AND SOFTWARE DEVELOPMENT
  2. APPLICANT ADDRESSES FOR MANUFACTURING AND DEVELOPMENT:

2.2.SYSTEM COMPONENTS NOT MANUFACTURED OR DEVELOPED BY APPLICANT:

2.3.INTELLECTUAL PROPERTY RIGHTS:

Page 1 of 7

CALIFORNIA APPLICATION FOR CERTIFICATION OF AN ELECTRONIC POLL BOOK SYSTEM

Part 3 of 4

REFERENCES

APPLICATION DATE:

e-POLL BOOK SYSTEM NAME AND VERSION:

  1. CERTIFICATION IN OTHER STATES
  2. FOR EACH STATE WHERE THIS EXACT VERSION OF e-POLL BOOK SYSTEM IS ALREADY CERTIFIED OR APPLICATION HAS BEEN MADE- Identify (a) the name of the state, (b) the date applied for certification, (c) the current status of that application, (d) the date approved, if any, (e) the reason for denial, if applicable, and (f) the name and contact information for that state. (Submit a copy of the document of approval or certification with the application).

(a) State / (b) Date Applied / (c) Status / (d) Date Approved / (e) Reason for Denial (if denied) / (f) State Contact Information
PendingApprovedDenied
PendingApprovedDenied
PendingApprovedDenied
PendingApprovedDenied
PendingApprovedDenied
PendingApprovedDenied
PendingApprovedDenied
PendingApprovedDenied

3.2.FOR EACH STATE WHERE OTHER VERSIONS OF THIS e-POLL BOOK SYSTEM ARE CERTIFIED- Identify (a) the name of the state, (b) the date first certified, and (c) the name and contact information for that state if not listed above and (d) version. (Submit a copy of the document of approval or certification with the application).

(a) State / (b) Date 1st Approved / (c) Contact Information / (d) Version

3.3. IF STATE APPROVAL/CERTIFICATON HAS EVER BEEN REVOKED ON ANY VERSION OF THIS e-POLL BOOK SYSTEM – Indicate (a) the state, (b) the e-poll book system version, (c) the date revoked, (d) the reason for revocation and (e) contact information for that state.

(a) State / (b) System Version / (c) Date Revoked / (d) Reason for Revocation / (e) State Contact Information
  1. JURISDICTIONS USING THIS e-POLL BOOK SYSTEM
  2. JURISDICTIONS OUTSIDE CALIFORNIA USING THIS e-POLL BOOK SYSTEM: Identify jurisdictions outside California that have purchased and used this e-poll book system. Indicate (a) the jurisdiction, (b) the population of that jurisdiction, (c) if it is the same version as is the subject of this application, (d) the date purchased by the jurisdiction (MM/YY) and (e) contact information for that jurisdiction.

(a) Jurisdiction / (b) Population / (c) Same Version? / (d) Date Purchased / (e) Contact Information

4.2 CALIFORNIA JURISDICTIONS USING A VERSION OF THIS e-POLL BOOK SYSTEM identify (a) the California jurisdiction name, (b) the type of jurisdiction (i.e. county, city, etc) and (c) the version.

(a) Jurisdiction / (b) Type / (c) Version / (a) Jurisdiction / (b) Type / (c) Version

Part 4 of 4

INDEX OF SYSTEM TECHNICAL DOCUMENTATION

APPLICATION DATE: e-POLL BOOK SYSTEM NAME AND VERSION:

Applicant must submit complete technical documentation for each e-poll book system component. All such documentation should be submitted in electronic format (MS Word or PDF). You must include: (a) technical and operational specifications, (b) identifying photographs, (c) operating instructions (for jurisdiction users), (d) maintenance instructions, and (e) training materials. Elections Code section 2550 lists six items an e-poll book system must contain: 1) Name, 2) Address, 3) Precinct, 4) Party preference, 5) Whether or not the voter has been issued a vote by mail ballot, and 6) Whether or not the vote by mail ballot has been recorded as received by the elections official. In column (f), please identify which document(s) and pages substantiate that the e-poll book system meets these requirements.

In the table below, identify the specific document(s), including filename, document version number, section and page numbers that satisfy the above requirements for each non-COTS component of the e-poll book system.

System component / (a)
Technical & operational specifications / (b)
Identifying photos (for hardware only) / (c)
Installation & operating instructions / (d)
Maintenance instructions
(for hardware only) / (e)
Training materials / (f)
Substantiation of Elections Code section 2550

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