Minority Coalition Membership Form
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Any individual can become a member of the Coalition by providing membership data and agreeing to support minority leadership, and the growth and development of the Coalition.
Individual members will not pay dues.
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Salutation:
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First Name:
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Last Name:
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Phone:
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Email:
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Street Address:
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City:
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State:
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Zip:
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Gender:
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Are you a registered voter?
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Have you ever participated in voter registration?
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What is your age range?
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What is the highest level of education you have completed?
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What is your current employment status?
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Would you be willing to volunteer to support the Coalition's work?
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Are you head of household?
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How many people live in your household?
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What are your most valuable skills?
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Are you a business owner?
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Do you have health coverage?
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Are you a homeowner?
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Are you of Hispanic, Latino, or Spanish origin?
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If you checked "Yes, another Hispanic, Latino, or Spanish origin", please specify (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
etc)
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Check all that apply:
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If you checked "Other Asian, Other Pacific Islander, or Other Not Listed", please specify:
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