Application Form – Daria Media

Name*

First Middle Last

Phone

Email

Gender*

Other (please specify)*

Age*

What is your current employment status?*

Unable to work (please specify)*

Address

Street Address

Do you have any disability*

-Please specify if Yes.*

Nationality

Country

Are you a registered voter?*

With regard to voting for the candidates/parties for the 2019 Presidential elections, are you:*

Are you influenced by:*

What are your top three questions for the candidates? (in order of preference) -Please specify which candidate(s) you are referring to.