*1.Group's Name(Required.)

*2.Group's Address(Required.)

Address

Address 2

City/Town

State/Province

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code

*3.Group's Phone Number(Required.)

Phone Number

*4.Type of Group(Required.)

Business

Church

College Student Organization

Fraternity or Sorority

High School Student Organization

Kiwanis Club

Masonic Lodge

Neighborhood/Community Association

Nonprofit Agency

PTA/PTSA

Rotary Club

Other

*5.Coordinator's Name(Required.)

*6.Coordinator's Email(Required.)

Email Address

7.Coordinator's Address
Only if different from group's address, above.

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

8.Coordinator's Phone Number
Only if different from group's phone number, above.

Phone Number

9.Preferred Area to Work in Orange County

*10.How did you hear about the Adopt-A-Precinct program?(Required.)