COS Surveyed

1. Email^*

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2. State^*

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3. Name^*

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4. Please select one of the following

House of Representatives, House of Delegates, or Assembly

Senate

N/A

Chamber to which you seek election

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5. Please select one of the following

Democrat

Republican

Libertarian

Independant

Other

Party Affiliation

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6. District Number

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7. How concerned are you about ^*

Unconcerned

Somewhat Concerned

Concerned

Very Concerned

Gravely Concerned

The federal debt crisis?

Judicial activism by the Supreme Court and other federal courts?

The extent of lawmaking being done by federal bureaucrats?

Congress legislating in areas reserved to the States?

Presidents making law through executive orders?

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8. If elected, would you support–and vote for–the Convention of States Project’s application for an Article V convention of the states limited to proposing amendments that “impose fi scal restraints on the federal government, limit the power and jurisdiction of the federal government, and limit the terms of offi ce forits offi cials and for members of Congress”?^*

Yes

Undecided

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9. If your answer to the last question was “No,” or “Undecided,” please explain.

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10. Best Email to Reach You^*

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11. If you would like more information, please let us know below. Check all that apply.

I would like to receive a personal briefing on this topic.

I am interested in attending a town hall meeting on Article V.

I would like more information about the Article V convention process.

I would like more information about Convention of States Action.

I am ready to support COS and do not need any more information.

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12. I am opposed to Article V, please explain.

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