1.

2.

3.

1. Are you registered? Republican
Democrat | Independent |
Libertarian Party? _________________
2. What state are you registered in?
___________________________

3. If the primary were held today
whom would you vote for?
_____________________
A. Rick Perry B. Herman Cain
C. Ron Paul
D. Mitt Romney
E. Michelle Bachmann F. Other

Are you registered? Republican

Democrat | Independent |
Libertarian Party? _________________
What state are you registered in?
___________________________
If the primary were held today
whom would you vote for?
_____________________
A. Rick Perry B. Herman Cain
C. Ron Paul
D. Mitt Romney
E. Michelle Bachmann F. Other

4.

What is your top issue for a

candidate you vote for?
___________________
A. Healthcare B. Foreign Policy
C. Job Creation D. Taxes
E. Drug Policy F. Nat. Debt

G. Other

Optional if Paul supporter

5. Would you like to come volunteer,
put up a sign, have a bumper sticker
or donate to the Ron Paul
campaign?
_________________________________

Full Name ___________________________

Name on facebook ______________________

Cell/phone ___________________________

Email _____________________________________

Address __________________________________

1. Are you registered? Republican
Democrat | Independent |
Libertarian Party? _________________
What state are you registered in?
___________________________

3. If the primary were held today
whom would you vote for?
_____________________
A. Rick Perry B. Herman Cain
C. Ron Paul
D. Mitt Romney
E. Michelle Bachmann F. Other

4.

What is your top issue for a

candidate you vote for?
___________________
A. Healthcare B. Foreign Policy
C. Job Creation D. Taxes
E. Drug Policy F. Nat. Debt.

G. Other

Optional if Paul supporter

5. Would you like to come volunteer,
put up a sign, have a bumper sticker
or donate to the Ron Paul
campaign?
_________________________________

Full Name ___________________________

Name on facebook ______________________

Cell/phone ___________________________

Email _____________________________________

Address __________________________________

4.

What is your top issue for a

candidate you vote for?
___________________
A. Healthcare B. Foreign Policy
C. Job Creation D. Taxes
E. Drug Policy F. Nat. Debt

G. Other

Optional if Paul supporter

5. Would you like to come volunteer,
put up a sign, have a bumper sticker
or donate to the Ron Paul
campaign?
_________________________________

Full Name ___________________________

Name on facebook ______________________

Cell/phone ___________________________

Email _____________________________________

Address ___________________________________