First Name: Last Name:

Home Phone: Work Phone:

Street Address: City:

State: Zip Code: Email:
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Work Location:

Work Address: City:

Availability:

YES! Count On Me To Volunteer For The Following: (Check all that apply)

Informational Picketing

Handbilling and Distributing Literature

Home Calls During Organizing Campaigns

Participate in Grassroots Political Activities

Rallies in the Community

Work on Phonebanks Making Phone Calls

Work on Organizing Campaigns