4/15/13 Voter Registration Survey

1. Motor Voter Program Survey

This survey is in full compliance of the National Voter Registration Act of 1993. All information obtained will be used for statistical purpose only. This survey is to be completed every first and third Monday of each month beginning on January 5, 2009. If you have any questions or would like to order additional supplies for the program, please contact Lisa Blake, MV Coordinator for the WV Secretary of State's Office at (304)558-6000 or lblake@wvsos.com.

Question Title

* 1. Complete the contact information below. This must be done each time you submit the survey.

Name: *

Agency: *

City/Town:

Email Address: *

Phone Number:

Question Title

* 2. Please enter the number of applications, recertifications, updates and changes of address that you have received since the last survey.

Number:

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* 3. Each client that falls in the above category is required to receive a voter registration application and a declination form. Note the number of declinations returned.

Total Declinations Returned:

Declinations Marked Yes:

Declinations Marked No:

Declinations Left Blank:

Question Title

* 4. Each client that received a voter registration application should return the form to your office for credit. Note how many forms have been submitted to the Secretary of State's Office.

# of VR forms complete: