Last Name		MI		First Name
Birthdate		Expected Graduation Year
School Phone Number				Cell Phone
Home Phone Number				Work Phone
School Address
School City, ST, ZIP
Home Address
Home City, ST, ZIP
Email
Father's Name
Mother's Name
On a scale of 1 to 10 (10 the most), how active do you want to be in CR?				1 2 3 4 5 6 7 8 9 10
Select as many that define your voting situation [hold down control (CTRL) to select more than one]				I am registered to vote at home at school with no party affiliation as a Republican I am not registered to vote