(Red fields are required) First Name: Middle Initial Last Name: Street Address 1: Street Address 2: City: State: Zip Code: Phone number: Email Address: Occupation: Select One Accountant Architect Athletic Trainer Attorney Auto Dealer Banker Barber Beautician Business Operator CEO/President of Company Chiropractic Physician Clergy Contractor Cosmetologist Dental Hygienist Dentist Dietitian Engineer Farmer Firefighter Funeral Director Geologist-Professional Homemaker Insurance Interior Designer Land Surveyor Professional Landscape Architect Law Enforcement Officer Librarian Manufacturer Nurse Optometrist Other Pharmacist Physician Private Detective Real Estate Retired Roofing Contractor School Administration Self Employed Social Worker State Employee State Employee-Retired Teacher/Staff-Grade Teacher/Staff-H.S. Teacher-Retired Union AFSCME Union Carpenters Union Electricians Union IEA-NEA-AFT Union Not Listed Union Operating Engineers Union Pipfitters Union Plumbers Union Teamsters Union UAW University Adm/Prof Veterinarian Other
Yes No Do you support the death penalty? Yes No Do you support the expansion of land based casinos? Yes No Are you a senior citizen and/or interested in senior citizen issues? Yes No Do you favor stricter gun control laws in Illinois? Yes No Do you believe Illinois should have Licensed Conceal Carry for gun owners? Yes No Do you favor a mandatory helmet law for motorcycle riders?
Yes No Are you a veteran?
Yes No Are you interested in veteran issues? Are you a member of a Labor Union? Yes No Which Union? I am not a Union Member Union AFSCME Union Carpenters Union Electricians Union IEA-NEA-AFT Union Not Listed Union Operating Engineers Union Pipe Fitter Union Plumbers Union Teamsters Union UAW Do you consider yourself to be: Pro-Choice Pro-Life All information will be kept confidential and not shared with commercial enterprises.
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