In working as an agent for the FreedomMaker Coalition of Indiana I agree to keep from disclosure all information given to me in the process of collecting signatures on the petition without express permission from the individual or the Coalition.
Petition Handler Registration
Full Name:
Street Mailing Address:
City, State, Zipcode:
Email:
Home Phone:
Cell Phone:
Indiana County:
Your District:
Number of Signatures
You Are Trying for:
In working as an agent for the FreedomMaker Coalition of Indiana I agree to keep from disclosure all information given to me in the process of collecting signatures on the petition without express permission from the individual or the Coalition.
YOU MUST HIT THE SUBMIT BUTTON TO SEND INFORMATION
IF YOU HAVE ANY PROBLEMS WITH THIS FORM EMAIL: datasupport@fmcoin.org
