VEA Membership Form

Voter Equality Association Membership Form
Name*

First NameLast Name
Birth Date*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a registered voter?*
Voter Verification*
Please enter the last 4 digits of your Driver's License / ID Card
Privacy Acknowledgment

By signing this form, I acknowledge that the Voter Equality Association will keep my personal information confidential and will not reveal it to any third parties without my explicit consent.
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Date*

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Date
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Voter Equality Association Membership Form