Name *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you willing to publicly endorse the CEQEC recommended ballot digitally and in print? *

Yes, I would like my name(s) added to the digital and print ads.

I support CEQEC but do not list my name in print or digital ads.

Yes, I would like to volunteer. Please contact me