We want to hear from you! Please fill in the short survey below with your question or issue. If you let us know how to reach you, we'll be happy to get back with you at our earliest opportunity!

Name
Email			Phone
Address				City	Camarillo Fillmore Meiners Oak Moorpark Oak Park Oak View Ojai Oxnard Pt. Hueneme Santa Paula Simi Valley Thousand Oaks Ventura Bell Canyon Westlake Village Agoura Hills Other
Education	High School or Less High School Graduate Some College Degreed College Graduate Post-Graduate College Work		Age	Below 18 18 - 25 26 - 35 36 - 45 46 - 55 Over 55

Current Student

at:

	How did you hear of us?		I'm interested in these services...
	House visit by Green Party member		Please send me your latest newsletter
	Phone call by Green Party member		Please contact me for upcoming meetings
	VC Greens event		Please add me to the VC Greens e-listgroup
	Heard GP Candidate Speak		Please contact me about future volunteer opportunities
	Current Green Party Member		I'd like to register with the Green Party
	Web Surfing		Please send me Green Party information
	Saw some party literature		Please contact me about any upcoming rallies
	Other		Please send me some buttons / stickers! (Specify quantities, below) GPVC Peace Party Button               VC Greens Sticker
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	Please include any other comments or questions you would like to send to us: