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ENDORSEMENT FORM
Please fill out this questionnaire
Candidate name
Elected office you are seeking
Political party affiliation
Have you ever been a member of any other political party ?
If so, please provide the dates of your prior affiliation(s) and the reason you changed your affiliation:
Address and contact information
Address
City
State
Zipcode
Telephone No.
Fax No.
Email
Website
Date of birth
Place of birth
Education (Beginning with High School and listing degrees received, if any) :
Work history (List full - time employment or full - time self - employment , whether in the public or private sector . List the business entities for which you have been an officer or director. List part - time employment at your discretion) :
Please list your other community involvement, membership in organizations, or other volunteer work in which you have participated ( Please specify dates of membership, all offices held within those organizations, specific candidates /initiatives you volunteered for and what you did):
Please list your other community involvement, membership in organizations, or other volunteer work in which you have participated ( Please specify dates of membership, all offices held within those organizations, specific candidates /initiatives you volunteered for and what you did):
Other elected offices held (please specify dates in office):
If you have previously held an elective office, list your accomplishments of which you are most proud ( Please be as specific as possible with respect to name of bill and date of passage or other specific action you caused while in office):
If elected, what specific goals do you have for your tenure in office?
If elected, what specific goals do you have for your tenure in office?
Please describe your view of the government’s proper role in regulating the business community:
Please list endorsements you have received for this election :
Submit
Thanks for submitting!
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