please download a printable version of this form and mail it to:

CONFIDENTIAL FORM - This information will help out campaign Efforts, as you wish to provide it.

FOR LEGIBILITY PLEASE PRINT CAREFULLY  Thank you for your cooperation, Vincent Dixon. 

Name : _________________________________________________________________

               First Name                        Middle Name                        Last Name

 Street Address : _________________________________________________________

                                Street Number       Street Name     Street Type ( Street, Avenue, etc.)

Town/City : ________________________State : ________________ Zip Code : _______ - _______

                                                                                                                                                       (Plus 4)

County :__________________________ Other District(s) :_________________________________

Telephone : H : (       ) _____-__________ Best Times : ____________________________________         

         W: (       ) _____-__________ Best Times : ____________________________________

            FAX : (       ) _____-__________  Email : ________________________________________________

Ward : _____ Precinct : _____ (If known, otherwise, we will look up this information.)

  Please check as many as apply :

 ___   Yes, I want to help Vince Dixon by :

 ___      Pledging My Vote

___      Giving A Contribution (Please make check out to Friends Of Vince Dixon - Limit is up to $500)

___      Pledging A Contribution – Can pledge $ ___________ per month.

___      Using My Name As An Endorsement  - If Yes Then Please Sign : _________________________

___      Using A Bumperstrip On My Vehicle

___      Using A Sign In/On My Yard, House, Window

___      Making Phone Calls

___      Help Hold A Coffee/Tea/Beverage Function For Vince

___      Hold A Fund Raiser

___      Being An Advisor On Issues

___      Being A City or Town Chair

___      Being A Ward Chair

___      Being A Precinct Chair

___      Campaign Organizing

___      Helping to Write/Help with News/Media Relationships

___      Other Items __________________________( Please describe further)