Prefix
* First Name
MI
* Last Name
Address Line 1
Address Line 2
City
State
Alabama
Alaska
America Samoa
Arizona
Arkansas
California
Colorado
Connecticut
D.C.
D.C.
Delaware
Federated States of Micronesia
Florida
Foreign Correspondence
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Trust Territory
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip
* Email
Phone
1. Do you believe our country is on the right track or wrong track?
Right track
Wrong track
2. What should be done with Obamacare?
Repeal and replace
Improve
Keep as is
3. Do you believe Congress should be a check and balance on President Trump or
help President Trump pass his agenda?
Check and balance
Pass agenda
Undecided
4. Do you approve of the job Rep. Zeldin is doing in Congress?
Yes
No
Undecided
5. Which issues are most important to you?
Economy/Jobs
Immigration/Border Security
Environment
Foreign Affairs/Terrorism
Healthcare
Spending/Debt
Taxes
Veterans
Education
Infrastructure
Other