CONTACT
INFORMATION
We are
Please
Print
Changing
South Carolina
______________________________________
Vote NO to Video Poker on Nov. 2
Name
______________________________________
Address
__________________________________________________________________
City
State
Zip
County
__________________________________________________________________
Home
Phone
Business
Phone
Fax
E-mail
Occupation_________________________________________________________
Yes, I am interested in serving on
the Organizational Steering Committee.
Yes, I authorize the use of my name
with Changing South Carolina.
____________________________________________________________
Signature
Date
I will take a leadership role in my
church. Name of Church_______________________
Denomination/Affiliation__________________ I am a
Pastor/Staff Lay Leader
I will take a leadership role in my
neighborhood. Name of neighborhood_______________
I will help in my club, group, or
organization. Name of group________________________
I will help in my precinct
Name of precinct _____________________________________
Steering Committee
Commitment Card
Signed__________________________________________________
Print Name______________________________________________
Telephone Number________________________________________
_____ I am willing to serve on the Steering Committee and authorize the
use of my name