First Name:  Middle Initial:  
Last Name:  Birth Year: 
Local No.:  Email: 
Home Street Address/APT: 
City:  State:  Zip Code: 
Home Phone:  Cell Phone: 

If you provided your cell phone number, may we text message you? 
Yes No

Registered Voter: Yes No

Workplace Industry: Grocery Store Meatpacking Poultry Retail Store
Other: 

What issues matter to you? Please check all that apply:

Organizing
Collective Bargaining
Wal-Mart
Immigration Reform
Social Security/Pension Protection
Health Care and Medicare/Medicade
OSHA/Health and Safety
Wages/Minimum Wage/Living Wage
40 Hour Work Week/Overtime
Right-to-Work
Education
Fair Trade Issues -NAFTA/CAFTA
Women's Rights/Civil Rights
Other: 

Would you be willing to volunteer? Please check all that apply:

Distribute Leaflets
Register Voters
Contribute Money to ABC
Write Letters-to-Editor
Write/E-mail Elected Officials
Set-Up Networking Among Co-workers
Volunteer for UFCW-endorsed candidates
Attend events and rallies
Attend town hall/county meetings
Lobby government officials
Participate in member-to-member home calls
Volunteer for Get Out The Vote (GOTV) activities