Full Name:__________________________________________________

Address:_______________________________________________________

City:____________________________________ State:________Zip:__________

Phone_____________________________________________________ (optional)

E-mail Address: _____________________________________________ (optional)

I can help by:
[___] General office work
[___] Telephoning
[___] Display lawn signs
[___] Putting up yard signs in my area
[___] Distributing literature at parades, fairs, etc.
[___] Distributing literature door-to-door
[___] Hosting a reception
[___] Fundraising
[___] Election day poll work
[___] Other: _________________________________________