Political Canvassing/Mailing List Form
Voter's Name:
First Name
Last Name
Voter's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Polling District:
Contact Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email:
example@example.com
Party Affiliation:
Registered to Vote?
Yes
No
Planning to Vote?
Yes
No
Voting Intention:
Supporter
Leaning toward candidate
Undecided
Leaning toward opponent
Supporting opponent
Prefer not to answer
Not at home
Needs:
More information
Absentee ballot
Ride to polls
Child care
Will support the campaign by:
Volunteering
Canvassing
Working to get out the vote
Making donation
Other
Additional Information/Issues:
Submit
Should be Empty: