Fillable Printable Application For Electronic Poll Book Certification
Fillable Printable Application For Electronic Poll Book Certification
Application For Electronic Poll Book Certification
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APPLICATION FOR ELECTRONIC POLL BOOK CERTIFICATION
State Form 55319 (R2 / 11-15)
Indiana Secretary of State
INSTRUCTIONS: 1. For evaluation of a new electronic poll book or reevaluation of a modification to a certified electronic
poll book, complete pages 1 and 2.
2. For renewal of a previously approved electronic poll book, complete pages 1 and 3.
This application is for the: (Check appropriate box.)
Evaluation of a new electronic poll book Reevaluation of a modification to a certified electronic poll book
Renewal of previously approved electronic poll book
APPLICANT INFORMATION
Name of vendor
Telephone number
Address of vendor (number and street or rural route)
Fax number
City, State, and ZIP code
E-mail address
Name of contact person for the vendor
Contact person’s telephone number
Product name
Model number
General description of system and the functionality of each component:
Hardware (including version numbers):
Firmware (including version nu mbers):
Software (including version numbers):
Reset Form
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This application must include the following: (Please check the box if material is include d with this application or indicate N/A, if not
applicable. If not included with this applic ation, material must be supplied before the application will be presented to the Indiana
Secretary of State)
1. Technical documentation including:
Executable image and source code escr owed with the Office of Indiana Secretary of State or its approved agent.
User manuals.
Operator and system manuals (including developer documentation).
Troubleshooting and training manuals.
Fail-safe and emergenc y backup information.
Equipment reliability estimate.
Environmental requirements for storage, transportation, and operation.
2. Photographs of the system; functional description of software components.
3. Engineering drawings.
4. Schematics or flowcharts identifying software and data file relationships.
5. Type of repair and maintenance offered by vendor.
6. Name and addresses of repair and maintenance providers.
7. Description of training courses (including both on-and off-site offerings).
8. A statement of the current and future interchangeability of all subcomponents.
9. Documentation of all testing performed on thi s system (internal or external sources).
10. Documentation of all internal q uality assurance procedures.
11. Documentation of all usability testing.
12. Documentation from election jurisdicti ons using or previously havin g use d the system or component.
13. Detailed information concerning electronic poll list consumables an d the vendor’s supply chain for those c onsumables.
14. Description of accessibility features and any testing performed.
15. Description of any kno wn anom alies, including a descriptio n of how those were resolved.
OATH OR AFFIRMATION
In making application for the certification of the electronic poll book or components listed above, I swear or affirm under
the penalty for perjury that to the best of my knowledge and belief all the information contained in this application is true
and the electronic poll book satisfies all functional an d technical specifications as descri bed in IC 3-11-8-10.3.
Signature Title
Date (month, day, year)
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PROCEDURES FOR RENEWAL OF A PREVIOUSLY APPROVED ELECTRONIC POLL BOOK FOR
USE IN INDIANA AFTER DECEMBER 31, 2015
You have applied for renewal of a previously approved electronic poll b ook (ePB) for use in Indiana. The Voting Systems Technical
Oversight Program must confirm that the ePB for which you seek renewal is identical to the ePB currently certified in the state and
conforming to the requirements listed in IC 3-11-8-10.3.
In order to complete our review of your renewal application, we require the following information (i n an attachment to this document):
A. Vendor Name
B. Model Name
C. Version Number
D. Hardware Components (including version numbers)
E. Software Components(including version n umbers)
F. Firmware Components(inclu ding version numbers)
G. Approved Peripherals(i ncluding version numbers)
H. COTS products authoriz ed for use with the ePB
I. Approved ECOs
J. Most recent Indiana Certification Date
K. A listing of Indiana counties where this equipment is currentl y deployed.
OATH OR AFFIRMATION
In making application for the renewal of the previou sl y approved electronic poll book listed above, I swear or affirm und er
the penalty for perjury that to the best of my knowledge and belief all the informat ion contained in this application is true,
that this electronic poll book is ide ntical to the previously approved and certified electronic poll book currently used in
Indiana, and satisfies all the functional a nd technical specifications as described in IC 3-11-8-10.3.
Signature Title
Date (month, day, year)
