I want to hear from you.

Your opinions and views are important to me. Please take a few moments to fill out this survey. I look forward to hearing from you.

Salutation:

Select OneMr.Mrs.Ms.Dr.Rev.Prof.Maj.Col.Fr.

First Name:*

Last Name:*

Home Phone:*

Mobile Phone:

E-mail Address:*

Address:*

Address 2:

City:*

County:*

State:*

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Zip Code(5-Digit):*

Do you support measures that would amend the U.S. Constitution to require a balanced federal budget? *

Yes

No

Other:

Do you support measures that would require a three-fifths vote of Congress to increase the amount of debt our nation carries? *

Yes

No

Other:

Do you support measures that would cut all spending not related to homeland security or defense spending across the board by 1-5%? *

Yes

No

Other:

What issues are important to you? (check all that apply) *

Economy/Jobs

Health Care

Domestic Drilling

Cutting Government Spending

Energy Security

Family Values

Defense & Military

Excessive Government Regulation

Other:

Questions/Comments:

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