Candidate Uptake Form – The Coalition of Independent Voters

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First Name*

Last Name*

Email*

Phone Number*

LinkedIn Profile URL*

Facebook Profile URL*

Other Social Media Profile URL*

Which U.S. state are you running in?*

Which office are you considering?*

Which district?*

Why did you wish to pursue this particular office?*

Are you a U.S. Citizen or Naturalized Citizen?*

If Naturalized, from what country did you move from?*

What year did you immigrate?*

What year did you obtain citizenship?*