Survey Form

Q1 : Choose three or more issues below that are most important to you and that could change the way you vote at a local government or state level. Put them in order of importance.

Order Selection:

Select from:

Q2 : Explain why you chose your first preference

Q3 : If you could talk to your local government councillors what would you tell them you would like them to do?

Q4 : Is there anything else you would like to say?

Q5 : Name

Q6 : Address

Q7 : Optional phone number

Q8 : Email

Q9 : Do you want to go on ParraCAN's elist? (To get a half dozen or so emails per year) Yes / No?

Yes

No

Q10 : Name of your local government council.