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Your Full Name * Title First Last Suffix
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
County *
Congressional District-
(number of district)-number only
Please make sure this is correct. *
Home Phone * ### - ### - ####
Cell Phone * ### - ### - ####
Work Phone * ### - ### - ####
Email *
verify email *
Birth Date * MM / DD / YYYY
I am a Registered Republican in New York State. *
Yes No In Progress
How have you contributed to the Ron Paul election thus far? *
Your Photo if Available
Are you a member of any Ron Paul Meetup Groups? Please list group numbers, separated by comma.(the number is in the URL of your group.) *
Have you ever been affiliated with a Political Campaign in the past? Please Explain.
1. I am a registered Republican voter in New York State. *
2. I support Ron Paul for President and agree to vote for him on every ballot at the Republican Convention until released by him from that obligation, regardless of any laws or rules to the contrary. *
3. I agree to attend the Republican National Convention in Minneapolis on September 1-4, 2008 at my own expense, and I have no personal or professional commitments or obstacles that could prevent me from attending the convention.

*
4. I agree to assist Ron Paul in a petition drive, if necessary, and to support his campaign in any other way I can so long as he remains a candidate.

*
Digital Signature *
Today's Date * MM / DD / YYYY
Do Not Fill This Out

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