EOA Enrollment Form

Name:*

Title:*

Municipality:*

Home Address:

City:

Zipcode:

Daytime Phone:

Evening Phone:

Fax:

Email Address:

Date First Elected:

Length of Terms in Office:

# of Terms Served:

Were Terms Served Continuously?

Hometown media sources (including addresses) for press release purposes:

Newspaper:

Radio:

Television:

Sponsor: