JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Request for Special Ballot
To vote in the October 20, 2014 Regina--Lewvan Federal Liberal Association candidate selection meeting
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Membership Information
This information helps us find your membership in our records
First Name
*
Your answer
Middle Name
Your answer
Last Name
*
Your answer
Membership Address
*
In Regina--Lewvan
Your answer
Membership Postal Code
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Home Phone Number
Listed on your most recent membership application
Your answer
Contact Information
If we have problems finding your membership in our records, or should you wish to have a special ballot mailed to an address other than the one on your membership file, we will need to contact you to verify this request.
Current Phone Number
*
Where we can readily reach you should we need to verify this request.
Your answer
E-mail
*
The one you check most regularly.
Your answer
Special Ballot Request Information
How would you like to receive your special ballot?
*
By mail, at the address provided below
By picking it up in person at 845A McDonald St. Regina on Monday, September 29 from 10am - 12pm
By picking it up in person at 845A McDonald St. Regina on Sunday, October 5 from 12pm -2pm
Street Address
Your answer
City
Your answer
Province
Your answer
Postal Code
Your answer
Acknowledgement
I am a current member of the Liberal Party of Canada, living in Regina--Lewvan, and I purchased my membership with my own money no later than 5:00pm on Wednesday, October 1, 2014
*
Please visit
http://www.liberal.ca/membership
to purchase or renew memberships
Yes
Required
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
