Name *

First Name

Last Name

Phone

Let us know in your message if you prefer to hear back via text or phone call

(###)

###

####

Are you a Waltham Resident? *

We want to hear from you regardless of the answer!

Yes, Registered to Vote

Yes, Too Young to Vote

Yes, Unable to Register to Vote

Yes, Not Planning to Vote

No, Not a Waltham Resident

Would you like to receive additional communications? *

Aside from responding directly to your message, can send you other relevant information?

Yes, add me to the list (or keep me on the list)

No, only respond directly to this message (or unsubscribe me)

Are you a "public employee" per campaign finance laws? *

Not sure? Watch the video at https://www.ocpf.us/PublicSearch/ViewDocument?id=3373

No

Yes

Address

Waltham Residents please provide the address where you are registered to vote (if applicable). Also, let us know in your message if you would prefer for someone from the campaign to visit you in person. Members of the Press (or others) please provide the mailing address of your organization.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country