* First Name:

* Last Name:

* Email Address:

Address:

City:    State:     Zip Code:

Home Phone:

Cell Phone:

Office Phone:

Do you have a laptop computer?   Yes   No

Do you have access to a car?   Yes   No

How much time can you work? Hours per week:

Are you interested in a leadership role?   Yes   No

Would you serve as a Precinct Captain?   Yes   No

Are you a Deputy Voter Registar?   Yes   No

Are you fluent in a language other than English?   Yes   No

If so, which language(s)?

What special skills and/or affiliations do you have that might be helpful?