New American Independent Party

RUNNING FOR OFFICE IN 2012
INTEREST FORM

First & Last Name

Address 1

Address 2

Town / City

State

+ 4 (0000)
if known

Zip Code

Phone Number

If so, which hours
or days do you
prefer?

Can we call
you?

NOTE: ALLOWING US TO SPEAK TO YOU BY PHONE WILL GREATLY SPEED
UP THE PROCESS. BUT, CONTACT BY PHONE IS NOT REQUIRED.

Email Address

Office level you are
seeking?

Year you intend on
running for office?

Office
you are
Seeking?

Other office
not listed
above

List your top 3 or 4 issues
that you want to run on or
what you hope to
accomplish

Have you ever
ran for public
office before?

YES

If yes, please expain (i.e. year &
position sought)

Have you ever been charged
with committing a crime?

Have you ever been convicted
of a crime?

Do you owe back taxes?

Are you familiar with the
NAIP/SRP Platform/ Issues?

Do you agree with the New
American Independent Party
/Self Reliance Party on most
issues? (We don't expect you
to agree with the platform on
every single issue)

Are you committed to helping
the NAIP/SRP grow and
become a powerful political
force in America?

Are you committed to running
under the "New American
Independent Party" ballot
label?

1. COMPLETE A CANDIDATE QUESTIONNAIRE FORM

2. COMPLETE A CANDIDATE DECLARATION/GOOD GOVERNMENT PLEDGE FORM

To request a NAIP candidate questionnaire (FORM 1) and CANDIDATE QUESTIONNAIRE/GOOD
GOV. PLEDGE (FORM 2) please email us at:
action@newamericanindependent.com

STEP 1:

Coming Soon!

STEP 3:

STEP 2:

PRESIDENTIAL
CANDIDATES
ONLY: