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2. First Name*
3. Middle Initial
4. Last Name*
6. What is your telephone number?*
7. What is your email address?*
9. Address
11. City
12. State
13. Zip Code
15. What type of data are you looking for?*

    1. Campaign Finance Report
    2. Jurisdictional Maps
    3. Statistics Report
    4. Voter History Report
    5. Voter Registration Report
    6. Other
17. Comments
19. Which of the following fields would you like included in your report?*

    1. Age
    2. Congressional District
    3. Ethnicity
    4. Gender
    5. Judicial District
    6. Mailing Address
    7. Municipality
    8. Name
    9. NC House District
    10. NC Senate District
    11. Political Party
    12. Precinct
    13. Prosecutorial District
    14. Race
    15. Registration Date
    16. Residential Address
    17. Status
    18. Superior Court District
    19. Telephone Number
    20. Voter Registration Number
    21. None of the Above
21. Comments
23. In what format would you like to receive your data?*

    1. Computer Printouts (Black & White, 8.5 x 11 - $0.20 per page)
    2. Computer Printouts (Color, 8.5 x 11 - $1.00 per page)
    3. Compact Disc ($25.00)
    4. Download (Free - Data will be placed on the Board of Elections website)
    5. District Maps (Color, 8.5 x 11 - $1.00)
    6. District Maps (Color, 11 x 17 - $1.00)
    7. District Maps (Color, 22 x 34 - $10.00)
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

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