Norths Side Issues Survey
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1. Default Section
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1
. Please tell us about you:
Please tell us about you:
Name:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code:
Email Address:
Phone Number:
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2
. Please check all the issues of concern in your neighborhood that are important to you:
Please check all the issues of concern in your neighborhood that are important to you:
Crime and violence prevention
Programs and jobs for our youth
Affordable housing/home ownership
Civic participation/voter registration
Neighborhood and playground clean-up
Living wage jobs with health care and pension
Empty lots/abandoned houses
Financial justice for Northside residents
3
. How would you be willing to help ACORN in your neighborhood?
How would you be willing to help ACORN in your neighborhood?
Door to door outreach in the community
Phone banking
Hold a meeting at my home
Come to an action
Contact voters to talk about the issues
Other (please specify)
4
. If you are not an ACORN member, would you like someone to contact you about becoming one?
If you are not an ACORN member, would you like someone to contact you about becoming one?
Yes
No
I'm already an ACORN member!
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