ACT Party Questionnaire
Register with the ACT Party
Email address *
What is your Name? (first last) *
Your answer
Your Email Address *
Your answer
Address - Street
Your answer
Address - Town/City *
Your answer
Address - Province/State *
Your answer
Address - Country *
Your answer
Address - Postal or Zip Code *
Your answer
Phone Number (optional)
Your answer
Would you sign the Petition to have an ACT Party in your Country and State or Province? *
Are you interested in becoming: *
Required
Comments or Advice to assist the ACT Concept
Your answer
Would you like sign our petition at Change.org?
Would you like to receive an ACT Newsletter?
Would you like to help CloudFund the ACT Party?
Would you like to share our Facebook site and help us all go viral?
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