Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

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###

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Check Below if Registered to Vote *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Currently a Precinct Leader *

committeeman, chair, etc.

Current Involvement *

(Check the one that applies)

Highly Involved

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