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2. 
4. Complete each section below. If not applicable, please enter "N/A." * fields required.
6. First Name*
7. Middle Initial
8. Last Name*
10. Street Address, Town, Zip Code*
12. Mailing Address (If different from above)
14. Email Address*
15. Home Phone
16. Cell Phone
18. Name of Committee

    2023 $0.05 Diesel Tax Ballot Question Committee

19. Your Position on the Ballot Question

    1. In Favor
    2. Opposed
21. Please fill out the next section if representing an organization.
23. Organization Name
24. Address, Town, Zip Code
26. Organization Phone
27. Organization Fax
28. Organization Email
30. State your interest and qualification to serve on this Ballot Question Committee in support of your position.*

    Use 200 words or less.

32. 
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

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