• 
• 
• 

• 
• 
• 
• 
• 

First Name: *
Last Name: *
Address: *
Address2:
City: *
State: *	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip Code: *
Phone:	- - Ext.
Email: *

Yes Alan! I support you in your campaign for Lodi City Council. You can count on me to...

	Place a sign in my yard.
	Display a bumper sticker on my vehicle.
	Walk a neighborhood.
	Make phone calls from my home.
	Write a letter to the editor.
	Assist at a polling place on Election Day.
	Receive email updates.

* Designates a required field.